CHAPTER XLIX
.
THE APPENDIX AND ITS DISEASES.[59]
[59] The laity, as well as part of the profession, having not yet ceased to wonder at the great importance attaching today to appendicitis, when twenty years ago it was practically unknown, it is worth while to insert here the following brief historical account: The term “appendicitis” was coined by Fitz for a condition which had not been hitherto unknown, but to which he gave a classical description. That the appendix might be primarily diseased had been known for one hundred and fifty years; that peri-appendicular abscesses were frequent may be seen by reference to works of the middle and latter part of the past century on perityphlitis and perityphlitic abscess, Willard Parker, of New York, being the most prominent writer of his day upon this subject. In the _Transactions of the Medical Society of the State of New York_ for 1875, Gouley reports a case of so-called perityphlitic abscess due to perforation of the appendix, with remarks upon its surgical treatment. The curious feature attaching to this case was that two years previous to its occurrence the patient had swallowed one of his teeth. Although this tooth was not found at the time Gouley alluded to the possibility of it or any other small body lodging in the appendix and finally causing ulceration. He referred also to the case published in 1856 by Dr. Lewis, of New York, who reported an individual dying at the age of eighty-eight, whose appendix was found to contain one hundred and twenty-two deer shot, it appearing that he had been exceedingly fond of game; he supposed that the shot found in the appendix were contained in meat which he had eaten. Lewis also referred to forty-seven cases of foreign bodies which he tabulated, all but one of which died.
Fitz’s article appeared in 1886. In it he claimed that operation should be done much earlier than was then the custom, and he showed that 34 per cent. of these cases died during the first five days of illness. But the first real operation for appendicitis as such was done by Krönlein, of Zurich, according to a suggestion made by Mikulicz in 1884. The second was done by Symonds, in England, in 1885, this being an interval operation. The first operation in the United States was done by Hall, of New York, in May, 1886, although to Morton, of Philadelphia, the credit must be given of the first operation in this country on a case deliberately diagnosticated. This was in April, 1887, Sands doing the next one in December of the same year.
McBurney had assisted Sands in a large number of cases, and in 1889 published his classical paper with an account of “The First Recorded Case where an Acutely Inflamed Appendix had been Removed while Full of Pus.” In the same year Weir also published an elaborate paper, making similar recommendations. It is not necessary to follow the subject later than the year 1889, since to it every surgeon of note has probably contributed.
=Anatomy.=--The vermiform appendix is an embryonic relic, and, like all such remains, is not merely superfluous, but often troublesome. That at some time it may have had an ordinary function is not to be denied; that now, in quadrupeds at least, it has one cannot be successfully maintained. Its past importance may, however, be perhaps indicated by the fact that in the ostrich, for instance, it is said to assume a length of six feet. Because of its relatively wide variations in size, length, and emplacement, as well as because of its mesenteric and other anatomical arrangements, its affections are often complicated and variable in the symptoms they produce. The appendix is, in fact, a miniature intestinal tube, having the same structure as the small intestine, though but greatly reduced. Its average length should be 8 to 9 Cm., the shortest on record being 1 Cm., and the longest perhaps 24 Cm. Its average gross diameter should be that of a No. 16 French catheter, but it may be found 1.5 Cm. in size. The average diameter of its lumen should be 1 to 3 Mm. The appendicular artery is given off from the right colic branch of the ileocolic artery, and it ordinarily divides into four or five branches, according to the length of the appendix and the extent of its mesentery. It derives its nerve supply from the superior mesenteric plexus of the sympathetic ganglia, which itself is connected with the right pneumogastric, this fact explaining many of the reflexes accompanying its diseases. In it lymph abounds and lymph follicles are numerous. Around its neck, as around the origin of every other embryonic canal (as Sutton has shown), is found a _collar of lymphoid tissue_ corresponding in structure to that seen in the pharynx. This tissue is inflammable, and succumbs easily to infection. Hence probably the apparent ease with which infection and gangrene occur in this locality. The position of the appendix is variable, and depends in effect on the development of the cecum and the degree of its rotation during this process. Its most frequent location (40 per cent.) is behind the cecum. In 30 per cent. of cases it occurs on its anterior surface or just at its lower end. It may lie as a free pouch with a loose mesentery, movable in the abdominal cavity, or it may be essentially a retroperitoneal affair not only not free, but even difficult to find. In direction it may vary correspondingly. Thus it may lie behind the colon, perhaps pointing straight upward toward the liver; it may hang in the pelvis, it may point toward the sacrum, or it may coil up anteriorly; and, according to the extent and freedom of its mesentery, in any of these locations, it may either be unattached and movable or quite bound down. Again, it may lie nearly straight or it may be kinked, bent, or coiled. It is necessary that the surgeon appreciate these possible variations, for they account for vagaries in symptomatology. In brief it should lie in the iliac fossa, at least, and to the outer side of the iliac vessels, but it may hang over into the pelvis in 20 to 25 per cent. of cases, or its tip may rest in a pocket or even in a subcecal fossa. In other words, it may be found in almost any attitude or position, these variations being explainable by peculiarities of fetal development. Furthermore it may even have its own _diverticula_, as has been recently shown. Normally it should be practically empty, save perhaps for a little muddy mucus. Very frequently, however, it contains fecal matter, and upon this fact depends much of its importance. If from retained fecal matter fecal concretions gradually result, then these become irritants and may produce either appendicular colic or may predispose to acute infection. Upon the retention of fecal contents should depend also a miniature peristalsis, and imitation of what goes on in the intestine above, in the production of a genuine appendicular colic. How annoying, painful, or even disabling this may be may be learned from the history of many a patient. On the other hand the appendix may become gradually occluded or obliterated, in whole or in part. If this process begin at its distal end and involve the entire tube it might be considered a fortunate occurrence for the patient. If, however, it be due to previous inflammation, or to subinvolution of the previous process, and if fecal concretions be thus imprisoned, it is hardly desirable and will frequently lead to trouble. More or less occlusion occurs in probably at least one-fourth of mankind.
Like the bowel above, the appendix may suffer in various as well as in similar ways. Thus in it may be seen pathological conditions which involve the bowel proper. Tuberculosis and actinomycosis may even occur here as apparently primary lesions, while cysts have been discovered within its walls, and such tumors as fibromyomas or primary adenocarcinomas are also met here. I have seen three or four instances of primary cancer of the appendix, and have now living one patient from whom six years ago I removed an appendix and adjoining portion of the cecum involved in most distinct cancer.
Again, the appendix participates in certain hernias and has been found in instances of strangulated or non-strangulated inguinal and femoral hernia, and has been seen also in cases of umbilical hernia. Twice I have found it in the inguinal canal and once in the femoral.
Furthermore when diseased the appendix, like the bowel, may contract adhesions to certain viscera, while it is now well known that it may attach itself to the kidney, the bladder, the right ovary, the tubes, or the uterus. This is of more than mere passing interest, for by such adhesions cases are not only surgically complicated, but diagnosis is made difficult, because of associated symptoms pointing to the organ thus involved.
=Foreign Bodies in the Appendix.=--Foreign bodies are occasionally found. This expression refers not merely to the fecal concretions above mentioned, which are practically small enteroliths. Thus, Kelly has mentioned cases in which ordinary pins have been found in this location, two of these cases being my own. In one instance I found the appendix to contain a round-worm at least three inches in length, and other intestinal parasites have been found by other observers. The laity have been greatly impressed by the reputed frequency with which grape and other seeds are found in the appendix, these figuring in their eyes as exciting causes of disease. In truth seeds are seldom found, that which has been mistaken for them being fecal concretions of various sizes and degrees of density. I have found actual seeds two or three times, but probably not oftener.
=Bacteriology of Appendicitis.=--Acute appendicitis being essentially an acute infection one inquires naturally which are the organisms most commonly involved. Answer to this question should be sought rather in the text-books on pathology, and should be summarized here by simply saying that the colon bacillus is perhaps more often found in connection with these cases than any other one organism. Streptococci and staphylococci rank perhaps next in frequency, while the pneumococcus, the capsule coccus, and all of the other pyogenic forms may be present, either as contaminations or in almost pure cultures. The fauna and flora of the intestinal tract afford ample opportunities for contaminations with many forms of microbes. If pus found here be a pure culture of any one organism it is most often of the colon variety, which is known to vary much in virulence, even when occurring alone. Mixed infections, however, are more predominant and more serious, especially in proportion as the more active pyogenic organisms appear in greater numbers. The bacteriology of appendicitis is then of great pathological interest, but concerns the surgeon very slightly, unless he have to do with some peculiar form, such as pyocyaneus, or a
## particularly virulent streptococcus.
[Illustration: PLATE LI
Illustrating Various Degrees of Involvement of Appendix Vermiformis. (Richardson.)
_A._ Chronic, recurring.
_B._ Chronic, much thickened.
_C._ Acute, with necrosis and rupture.
_D._ Showing necrosis of mucous membrane.
_E._ Gangrene and perforation, permitting fecal extravasation.
_F._ Total gangrene without perforation.]
=Appendicular Colic.=--Sufficient has been said above regarding the appendix as a miniature intestine, its outlet guarded by the little valve of Gerlach, to afford an anatomical reason why conditions even in the larger bowel should be imitated here. Some writers have not placed as much stress upon appendicular colic as I would here. One sees many instances of it if he will only recognize it, the frequency of its occurrence not only disturbing the comfort of patients, but keeping ever before their minds the necessity for operation. An absolutely empty appendix will be free from all abnormal activity of this kind, but when a little fecal matter has become imprisoned, and when by its long retention fecal concretions have formed, they may give rise to considerable disturbance without actually producing inflammation, the former being due to the spontaneous effort of the appendix to expel them. This effort may be excited by other conditions in the bowel adjoining, but by itself it may be the essentially relatively violent muscular effort which produces pain and is followed by soreness. That not a few cases of acute appendicitis commence with an appendicular colic is extremely probable, and that it may occur at frequent intervals and never pass the colicky stage is equally true. _Appendicular colic, then, may be a precursor of an infectious appendicitis, acting as a predisposing cause, or either may occur independently of the other._
Indications of this form of colic are frequent, viz., nagging pains in the region of the cecum, which may last a few moments or a few hours and then subside, leaving a tenderness which persists for a day or two, after which the patient seems to be free for a longer or shorter interval, to suffer again and again in the same way. These attacks may be accompanied by some nausea, will be found frequently associated with whatever may have disturbed ordinary intestinal activity, and may even produce a mild degree of fever, which latter is partly due to mental perturbation and partly to a mild degree of toxemia, the latter being possible in connection with abnormal appendicular activity, as the _appendix itself is a closed sac_ and the very materials which it is trying to expel may furnish the toxins.
It is difficult to distinguish between appendicular colic and mild attacks of catarrhal appendicitis. The transitory nature of the former is its particular diagnostic feature, coupled with absence of all lasting indications.
The following would seem the simplest working classification of lesions of the appendix.
{Catarrhal. Endo-appendicitis. { {Diffuse. Parietal or {Hyperplastic. { interstitial. {Obliterative. { _A._ Acute. { {Intertubular. {Purulent. {Intramural. { {Peri-appendicular. { Any of these may lead to {Gangrenous or {Perforative lesions.
_B._ Subacute. Recurrent or relapsing.
_C._ Adhesive or obliterative.
Almost any of the above forms may be associated with diseases of other abdominal viscera, as, for example, with typhoid. Thus out of 119 autopsies on typhoid patients 19 showed changes in the appendix corresponding to those produced by the typhoid organisms in other portions of the intestines. (Kelly.) Of 3770 autopsies on tuberculous patients tuberculous lesions were noted in the appendix in 44 instances. The appendix may also become involved with any form of ileocolitis, either in the young or in the adult. Again an infection of the right tube and ovary may easily extend to and involve the appendix, just as infection may travel in the opposite direction. (See Plate LI.)
Before discussing the causes of this condition it is advisable to take a comprehensive view of the entire subject in its pathological relations. As Dieulafoy has shown, appendicitis is the consequence of the transformation of the hollow conduit into a closed cavity, whose length and narrowness make it liable to such changes, for which various causes are to be assigned: for example, the formation of calculi or concretions which are quite comparable to renal or biliary and which lead to a true appendicular lithiasis. There is even reason to believe that a calculous appendicitis may be hereditary and belong to the patrimony of gout. At other times it is the consequence of local infection, followed by tumefaction, and corresponding to obstruction of the Eustachian or the Fallopian tubes. Again it results from slow, progressive fibrous alterations or from the strangulations due to twisting or formation of adhesions. In any event the closed cavity varies in size and shape, and does not necessarily lead to self-destruction unless the bacteria thus pent up are sufficiently virulent. At all events the attack declares itself only when the cavity is actually closed, and it is then that imprisoned bacteria, previously harmless, multiply and intensify their virulence, as they do in a blocked loop of bowel. At times an acute intoxication from toxins is produced, and may be so pronounced that patients succumb to it almost before the characteristic lesions, or any local peritonitis, has become fairly outlined. On the other hand if retained bacteria be but slightly virulent, or have been successfully conquered by phagocytes, or if the canal has become pervious again, the attack may spontaneously subside, although there is great probability of recurrence. In many instances the infection ends in ulceration, abscess, gangrene or perforation, all of which may give rise to peritonitis of varying extent and severity. Germs may traverse the walls of an affected appendix without perforation. It may then become the direct cause of peritonitis, septicemia, or hepatic abscess.
=Recurrent Appendicitis.=--_Every attack of appendicitis, no matter how mild, predisposes to a repetition of the trouble, in mild or in fulminating form._ Every appendix once inflamed has had its blood supply compromised and may break down easily upon a second attack. While not every patient who has once suffered in this way should necessarily suffer again, the majority who have had one attack may have another. No one can be prophetic in this regard and no one may truly assert that several mild attacks may not be followed by another most severe. That an appendix has been once inflamed is sufficient to justify its subsequent removal. That it has been several times involved makes operation next to imperative. Even repeated attacks of appendicular colic predispose to trouble in this region. In any appendix which has in this way frequently excited suspicion, or which gives rise to frequently recurring though mild colicky pain and local tenderness, especially when coupled with mild stercoremia, indications are for removal. It may be safely laid down, then, as a rule, to which there should be few exceptions, that _any appendix which causes frequently recurring or almost continuous trouble should be removed_.
=Causes.=--It is impossible in any brief summary to include all the possible causes of appendicitis. Those mentioned below are perhaps those most commonly recognized or pronounced, yet the list is far from complete. First of all it should be remembered that the disease occurs in a vestigial organ, containing relatively considerable lymphoid tissue, especially around its neck, that it is comparatively poorly supplied with blood, and that such tissue under such circumstances inflames easily and breaks down quickly. Doubtless the trouble in some instances commences within the tiny intestinal tube. At other times its originating cause lies without, as, for instance, when its blood supply is interfered with by pressure of an overloaded cecum, by tumors, or by violent intestinal activity; this especially in connection with an appendix firmly anchored and not freely movable, it being so fixed in many instances that it cannot readjust itself easily to varying conditions. Thus an overloaded cecum may first press upon the appendix and then by violence of activity so displace it that it may easily succumb. Again in those appendices which hang downward into the pelvis there is little or no drainage by gravity, and they may easily become overloaded. A movable kidney may also disturb the integrity of an appendix in certain locations. Foreign bodies frequently excite pernicious activity, especially fecal concretions, and actual calculi or miniature enteroliths. Traumatism sustains a certain relation to some cases of violent activity of the psoas muscles in athletes, which may upset the circulation of appendices which lie directly upon the muscles involved.
Many of the causes mentioned above are predisposing rather than actual. The actual exciting causes of acute infection have mainly to do with _germ activity_ and with _vascular supply_. It is well known that the more virulent the organisms the more acute the resulting inflammation, and it is also well known that colon bacilli and the ordinary pyogenic organisms vary in virulence within wide limits, and that mixed are often more acute than simple infections. Typhoid bacilli, tuberculous bacilli and the like vary in the same way, and, in company with other germs, may easily light up serious disturbance.
=Complications.=--Of the complications which may accompany or ensue upon appendicitis the most common are those which involve the peritoneum, either local or general. Acute peritonitis is to be feared not only because of its autotoxic expressions, but because of the acute obstruction which it may produce by gluing intestinal loops together and paralyzing their motility. When to more or less widespread peritonitis are added general sepsis, with all its possible complications, and such further local expressions as cellulitis, which may be pericolic, subphrenic, perineal, or pelvic, or phlebitis which, involving the portal system, would soon lead to formation of hepatic abscess, it will be seen how easily the case may become serious. Furthermore not only may the ovary and tube suffer, but cystitis and nephritis may occur as toxic complications, while finally, by violence of the ulcerative process, a fecal fistula may form. This is by no means a complete list, but includes some of the more frequent complications.
=Symptoms of Acute Appendicitis.=--_Pain with nausea, tenderness_, and _rigidity_ constitute the triad of the most indicative early signs and symptoms, each of which needs to be considered by itself.
=Pain.=--Pain is at the same time an important yet variable feature. In few other acute lesions does it vary as much in degree and location. Generally it is referred at first to the more central portion of the abdomen, as around the navel or between it and the right side of the pelvis. Later it may be localized at some widely distant point, as, for instance, far over upon the left side. Such vagaries may be held to be due to peculiarities of emplacement of the appendix, and would indicate that the organ will probably not be found in its most common location, but rather extending to the left or hanging over into the pelvis. When the appendix is attached to or lies near the bladder there may be considerable pain in the pelvis and in the bladder. It should be remembered that the parietal peritoneum is much more sensitive than the visceral, and in proportion as the lesion approaches the surface more exact information may be gathered from location of pain. Occasionally it may be referred to the region of the gall-bladder, or even to the chest above the diaphragm. In some instances it is agonizing, almost from the outset; in others it is never very severe. The rapidity of the process may be measured to some extent by the intensity and character of the pain. When the disease resolves slowly and kindly pain _gradually_ subsides, but the _sudden_ subsidence of pain, especially without equal improvement in other respects, is a _bad_ rather than a good sign, indicating probably that perforation has occurred.
=Tenderness.=--Tenderness is a more constant and persistent and, therefore, a more reliable indication than pain, and, as well, less misleading. No matter where the patient may seem to feel pain the actual tenderness will indicate the location of the appendix itself. Thus even if pain on the left side be severe, tenderness will not accompany it, but will be found centred at the location of the appendix. This is a fact of great importance. In his first paper on appendicitis McBurney showed that the appendix is most commonly located at a point beneath a line drawn from the umbilicus to the anterior superior spine and one and a half or two inches away from the latter. This has since been known as McBurney’s point. To it, however, too much importance should not be attached, since the appendix is often not found under this area, and tenderness may be found at a distance two or three inches away from it. Over the actually tender area the skin will also be hypersensitive, and this intense hyperesthesia is also an indication of considerable value.
=Rigidity and Muscle Spasm.=--Rigidity and muscle spasm are to be carefully studied, and upon them much reliance may be placed. With the first onset of pain they may be general, but they usually become more and more localized, unilateral, and finally limited, save in those instances where general peritonitis has begun and is spreading. For instance, Richardson regards it in this light: “Rigidity with distinctly localized pain strongly suggests appendicitis; with fever it almost proves it; with tumor it fully establishes diagnosis.” When to ordinary abdominal rigidity is added actual muscle spasm, provoked by even light palpation, and occurring in the rectus or one of the flat muscles lying in close relation to the appendix, then a still more important indication has been obtained. When true muscle spasm involves all the abdominal musculature general peritonitis has probably begun.
=Tumor.=--The presence of tumor in the suspected area will nearly always be a corroborative sign, but diagnosis should not depend upon its presence. It is hardly to be looked for during the early hours or perhaps days of an ordinary attack. It may be due to fecal impaction in the cecum, to outpour of exudate, to binding together of omentum and intestine, or to the presence of pus. If a considerable mass can be detected within the cecum during the early hours of an attack this should be regarded rather as an expression of coprostasis and impaction, to which the attack itself may be due. Tumor, therefore, is significant when present, while in some instances its absence is still more so.
=Vomiting.=--Vomiting is an irregular and uncertain feature. Probably the majority of cases begin with nausea (after the initial pain) or with vomiting, either one without the other, or with both combined. Likely through the course of the disease vomiting may be an occasional disturbing element, though patients may have no nausea whatever.
=Bowels.=--The condition of the bowels and their behavior will depend very much upon their actual state at the moment of attack. Some attacks seem precipitated by violent intestinal activity; here diarrhea or dysentery will be an early feature. Others are precipitated rather by overloading of the cecum; in these cases constipation would be a well-marked feature. Bowel inactivity is to some extent an expression of bowel paralysis due to toxemia, which in some instances is profound, in others slight.
=Temperature.=--The temperature is also a variable and uncertain feature. It may be normal at first or very high. At any time it may rise gradually or suddenly, and may subside in the same atypical way. Taken by itself it is an unreliable feature. When, however, temperature steadily rises the surgeon may take alarm, and if the pulse rate goes up correspondingly the case takes on a serious aspect. A sudden fall of temperature is almost as serious a feature as a sudden rise. A normal or subnormal temperature may be seen when a large amount of pus is present, or but a minimum of disturbance may be found when operating upon a patient whose temperature is 104°.
=The Pulse.=--The pulse is a more reliable guide than any obtained with the thermometer, its rapidity being proportionate to the gravity of the disturbance. _A constantly rising pulse is a serious indication_, especially if accompanied by vagaries of temperature. Some operators regard the pulse as a sufficient indication for operation, holding that when it rises above 112 operation should be made. I hold this to be a good rule, but would not have it interpreted as indicating that operation should not be done unless the pulse attains this figure, and believe that, no matter what the other conditions, the final indication has arrived when the pulse goes above 112.
=Abdominal Distention.=--Abdominal distention may be due to gas formation, to constipation, or may indicate the paralysis of peristalsis. When it becomes well marked it is a serious indication, and when toxemia is profound no sound whatever will be heard within the bowels thus distended. It usually indicates the onset of general peritonitis. It is unfortunate in more than one respect, since intra-abdominal conditions are masked by it and operation complicated, it being sometimes impossible to restore the bowel to the abdomen without at least partially emptying it.
=Jaundice.=--Jaundice, when occurring, is a toxic expression, possibly due to temporary obstruction of distended or paralyzed bowels.
Finally the _general appearance_ of the patient will be suggestive, patients with serious conditions having always an anxious or haggard facial expression, rarely moving themselves easily or freely in bed, or smiling at anyone or anything, their faces being perhaps somewhat flushed, their expression and action being apathetic, while perhaps later there will be delirium with restlessness. When the face is pinched, the eyes sunken, the nose sharp, the skin dusky, and respirations rapid and unsatisfying, as well as of thoracic type, any intra-abdominal infection may be regarded as serious and unpromising.
What shall be said about the _value of the blood count_? It is possible in nearly every instance to make a diagnosis of appendicitis without the aid of the microscope, as well as even to judge of the advisability of immediate or postponed operation. Nevertheless an indicative differential blood count, an affirmative result of the iodine test, or the discovery of indican in the urine, may afford positive corroboration in cases where doubt may have existed. In reality, however, any case which will furnish satisfactory and distinct responses to these tests should be recognized without them. A leukocyte count above 12,000, in connection with other indications, is usually sufficient to justify operation. A very high leukocytosis--_e. g._, above 24,000--is a matter of great importance. In the more chronic cases the leukocytosis is but slight.
=Diagnosis.=--Obvious and indicative as many cases of acute appendicitis are from the outset, there are still others when one may be in serious doubt, even for some days, either because patients do not clearly state their own symptoms, because of peculiar reference of pain, or because of the co-existence of complications, each of which may mask the other.
_Colitis_ of adults and _enterocolitis_ of children will produce sometimes severe attacks of pain, with cramps and local tenderness, that may at first mislead. There is a form of _mucous colitis_ which is now more generally recognized than in time past, in which diagnosis is sometimes quite difficult. The onset is often sharp, while the right iliac fossa may be occupied by an elongated, resistant, tender mass, showing fecal impaction within the cecum. On the other hand the same condition may be met in the left iliac fossa, and will thus indicate that the sigmoid is especially at fault. In these conditions there is often actual exudate around the inflamed bowel, and this may even break down; it is proper then to speak of a _circumscribed colitis_, and there is reason to think that in certain cases it arises from infection of a diverticulum from the large bowel. The pain is not infrequently complained of at the so-called McBurney point. In not a few instances the appendix has been removed when under perfectly natural suspicion, and found so slightly involved as to show that the actual trouble was in the cecum rather than in the appendix itself. Dieulafoy believes, in fact, that formerly the cecum was made too much of and the appendix disregarded, while today these conditions are sometimes reversed.
From _gallstone disease and cholecystitis_ its symptoms are sometimes quite difficult to distinguish. Especially is this true when pain is not accurately localized, and when, on the other hand, muscle spasm and tenderness are widespread. The previous history of the case will give much aid in this matter, while the pain in gallstone trouble radiates rather toward the right shoulder, in appendicular disease toward the umbilicus or downward. When dulness on percussion shades directly into liver dulness the gall-bladder is naturally the more to be suspected. When patients themselves cannot make minute distinctions in description of pain and tenderness the condition may be difficult of recognition.
=Peritonitis.=--_The majority of all attacks of so-called idiopathic peritonitis spring from appendicular disease_, at first and perhaps throughout unrecognized. A condition of peritonitis, then, for which other explanation is not found may be considered as, in all probability, due to appendicitis whose peculiar features may have been masked. It is not difficult to recognize a condition of general peritonitis. The great difficulty is to ascribe its proper cause. As already and elsewhere indicated these conditions merge into expressions of acute obstruction which still further complicate the case, and it is by no means infrequent to have this order of events: an acute gangrenous appendicitis followed by local peritonitis, with adhesions, which, becoming dense, rapidly produce obstructive symptoms, the condition going even farther and gangrene spreading from the appendix proper to any or all of those intestinal loops which come in contact with the primary focus, so that when the condition is thoroughly revealed it is found to be one of multiple gangrene of the bowel as well as of fierce and septic peritonitis.
_Gastric and intestinal ulcers with perforation_ are easily mistaken for appendicitis, especially when the duodenum is involved. In at least half of the recorded cases of perforating duodenal ulcer the condition has been at least at one time supposed to be one of acute appendicitis, while after perforation has occurred and the matter which has escaped has worked its way down toward the right iliac fossa the similarity of conditions will be all the more striking. If an accurate history can be obtained there will probably be learned from it that which will tend to avoid mistakes. The exceedingly abrupt and acute onset of symptoms will also be more pronounced than in most cases of commencing appendicitis. This is true also of the perforations of typhoid ulcer, especially of “walking typhoid.” While acute appendicitis during the course of typhoid is by no means unknown, the abrupt onset of pain, rigidity, and tenderness during the third week or later would suggest perforation very much more than the possibility of an appendical lesion.
_Acute obstruction of the bowel_ due to other causes than appendicitis--_e. g._, volvulus or intussusception--might give rise to symptoms which would be regarded as indicating appendicitis. This is true also of _strangulated hernias_, especially the internal forms, since there will be no excuse for failing to discover an external strangulation of this kind. _Lead colic_ may simulate some of the milder and more chronic forms of appendicitis, from which it should not be difficult to exclude it by its history, the occupation of the patient, and the appearance of the gums.
The _kidneys and ureters_ are sometimes so involved as to occasion doubt. A _floating kidney_, with its possible crises, displaced into the right iliac fossa, where it might be mistaken for an inflammatory mass, might thus cause some hesitation. So also might the acutely suppurative forms, the formation of a sudden phlegmon about the kidney, or the entanglement of a calculus, either at the hilum or along the ureter, produce severe pain, tenderness, and fever, which would at first easily perplex. The pain of renal colic, however, is usually more agonizing, beginning in the flanks and referred down along the ureters to the genitals and the inner side of the thigh. It may also be intense in the back, and may be accompanied by nausea and vomiting. Renal colic is also nearly always accompanied by frequent urination and sometimes by the appearance of blood in the urine. With an impacted calculus at the lower end of the ureter at the level of the appendix diagnosis may be very difficult. Here the _x_-rays may afford some assistance.
_Acute pancreatitis_ begins with intense abdominal pain that may at first suggest appendicitis. The pain, however, is usually epigastric; abdominal distention comes on early; vomiting may be profuse, and the tenderness is most marked along the left costal border. There is, moreover, a more profound prostration, sometimes accompanied by cyanosis. An acute suppurative pancreatitis may soon be followed by peritonitis, which when seen will so completely mask all symptoms that diagnosis as between the two is quite impossible, but symptoms which can be accurately localized will usually point to the upper rather than to the lower abdomen.
_Mesenteric thrombosis and embolism_ are rare conditions which commence usually with fulminating symptoms and produce intense agony, with tenderness and rigidity all over the abdomen. Their onset is so profound that patients fall into a condition of extreme collapse within the first few hours, and their tendency is so rapidly to the bad that they are not likely to be mistaken for acute appendicitis.
The _pelvic viscera of women_ also furnish acute inflammations, such as _pyosalpinx_, with or without rupture, that sometimes precipitate very acute symptoms which may point to the abdomen rather than to the pelvis. In many of these instances the appendix is more or less adherent to the adnexa on the right side, and infection in either one may easily travel to the other, so that both become ultimately involved. Local examination will reveal the existence of pelvic conditions, in whose absence there may be justification for inferring that the trouble has not originated in that cavity.
_Ruptured extra-uterine pregnancy_ has been in numerous cases mistaken for acute appendicitis. It usually begins with violent pain and pronounced muscle spasm, with more or less shock. I have repeatedly been called to operate for appendicitis and found the other condition present. The operator may be prepared to find it if he elicit a suggestive history or if a vaginal examination reveals a pelvis more or less filled with semisolid material. Amenorrhea does not always signify ectopic gestation, yet when doubt arises it would be advisable to inquire carefully into the menstrual habit of the patient. On the other hand it is known that acute appendicitis may bring on uterine hemorrhage. When, however, the possibility of pregnancy exists, along with a history of menstrual irregularity, or of hemorrhages unaccounted for, and one finds within the pelvis the uterus pushed forward or displaced, or perhaps an irregular tumor, he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis occurring _during pregnancy_, or still worse, as I have seen it, _e. g._, in a woman with a large uterine myoma, gone to about the seventh month of pregnancy, and then suffering from an acute peri-appendicular abscess, the whole proving more than she could withstand.
With an appendix placed behind the cecum it will usually rest upon the psoas muscle, where it may be disturbed by violent exercise, or where it may lead to mistaken diagnosis either in case of acute inflammation of the muscle itself or of acute appendicitis. When the right limb is drawn up, and especially when all motions of the limb give pain, we may believe at least in the participation of the muscle in the inflammatory
## activity. On the other hand, an insidious _psoas abscess_ may give
rise to a certain degree of tenderness in the right iliac fossa, with flexion of the thigh, and gradual development of tumor, which may be mistaken for chronic appendicitis.
The possibility of _appendicitis occurring during typhoid_ has been mentioned. Differential diagnosis between the two conditions will ordinarily not be difficult when one can obtain an accurate history. In classical appendicitis pain is always the first symptom, and temperature rarely rises until a number of hours at least after the first attack of pain. Even the milder typhoid cases may show tenderness in the right iliac fossa, but one should look for the characteristic eruption and make a Widal test. The presence of splenic enlargement would point to typhoid, as would also the occurrence of bronchitis, epistaxis, or headache, with perhaps albuminuria. The most perplexing cases will be those of _perforation_, perhaps even of typhoid ulcer of the appendix. In these cases acute pain will usually indicate perforation.
_Intrathoracic affections_ sometimes begin with or are accompanied by severe pains which are referred to various parts of the abdomen and cause great confusion. Thus I have repeatedly seen pneumonia, even on the left side, regarded at least at first as acute appendicitis, because patients referred most of their pain to the abdomen rather than to the chest, while the abdominal muscles participated to such an extent as to produce pronounced rigidity. Here a blood count would scarcely help, but careful physical examination of the chest would reveal the difficulty. _Such examinations should be made when respirations become irregular, or when the breathing is evidently in any way embarrassed._ Acute pneumonia and acute pleurisy, especially diaphragmatic, may have then to be differentiated from acute appendicitis.
Finally, _hysteria_ is an element not to be disregarded in some of these cases; not that it is likely often, if ever, to lead to serious doubt, but that patients with the hysterical or neurotic temperament are constantly tempted to so seriously exaggerate their complaints as to lead to at least a more serious view regarding themselves than circumstances justify. Thus a mild appendicular colic in a neurotic patient may produce a disproportionate complaint, and one must be ready to assign to hyperesthesia or exaggerated complaints their proper value.
The _symptomatology of appendicitis_ may then be summarized briefly as follows: When pain comes on suddenly and is referred to the lower part of the abdomen, or even its central region, becoming perhaps more localized as the hours go by, is shortly followed by nausea or vomiting, and this by general abdominal sensitiveness, with an increasing degree of rigidity; and when temperature, which at first is not elevated, begins to rise in from twelve to twenty hours, then it may be held that this is a classical picture of an attack of acute appendicitis. So strongly does Murphy, for instance, hold to this order of events that he even questions diagnosis when symptoms are not thus timed, and especially if vomiting precede pain.
When pain which has been severe subsides, and comes on afresh after an interval of perhaps thirty-six hours, it is to be regarded as due to fresh peri-appendicular involvement, and is an unfavorable feature. _In fact the subsidence of pain and apparent improvement often noted do not always mean actual improvement, but may be the forerunners of a still more dangerous condition._ Thus the “perilous calm” of appendicitis should hasten operation, or at least increase watchfulness, rather than beget confidence. Should one rely too much upon them and procrastinate he will find that his mortality rate will rise accordingly. The statement elsewhere quoted in this work that “the resources of surgery are rarely successful when practised upon the dying,” will apply here.
There is scarcely any equally limited area of the body in which as many varied and widely different pathological conditions may be exemplified as in the appendix and the space immediately around it. The mildest degree of hyperemia or vascular engorgement, the most destructive form of inflammation, with fulminating necrosis, may here be observed. Moreover, conditions commencing under one type may quickly change and the whole type of an attack may within a short time be merged from the mildest into the most severe.
In _catarrhal or endo-appendicitis_ it is mainly the mucosa which suffers. This may undergo merely a congestion, with increase of discharge, and, so long as the outlet be not completely obstructed, may be a purely temporary matter of but a few hours’ duration, or it may extend over a few days. The purulent or more destructive forms may commence in either of the coats of the appendix. It is no uncommon thing to find a necrotic mucosa with a still unbroken serosa, or a perforation of the outer coats and a hernial protrusion of the inner, perhaps just ready to give way. In location and extent the _suppurative and destructive process may also vary_. Whereas ordinarily the distal portion, being less supplied with blood, will suffer first, it is not uncommon to find perforation at the junction of the appendix with the cecum, or even gangrene of a limited area of the cecal wall itself. Again, at times, the trouble seems limited to accumulation of pus within the appendix, _i. e._, an _empyema of the appendix_, without great tendency to involve the structures adjoining, and an appendix may be found containing a few drops of pus or distended almost to its bursting point still free or but slightly attached by exudate. In the milder cases there may be found strictures indicating the site of previous lesions. Again, aside from pus, there may be more or less fluid or semisolid fecal matter or dense concretions, in addition to the possible foreign bodies whose presence has been elsewhere considered. In the more subacute or chronic forms there will be found relics of previous rather than active expressions of present trouble, such as strictures, thickenings, contortions, old adhesions, sometimes quite dense, and contained concretions, or other foreign bodies, or one may find appendices shrivelled up or more or less obliterated (appendicitis obliterans).
The role of the omentum has elsewhere been mentioned, but must be alluded to again at this point, since it participates more or less in almost every case of acute appendicitis. The moment the appendix is acutely inflamed the omentum tends to shift itself over toward it and finally around it, and it is not uncommon to find a gangrenous appendix wrapped in a roll of this kindly disposed fatty apron. In fact this may constitute the tumor which may have been already discovered and found to be fixed or movable. The inner surface at least of the omentum thus applied will nearly always have sacrificed itself and one has need usually to remove a considerable area of gangrenous omentum, as well as the appendix itself, feeling as he does it that he is necessarily sacrificing the best friend that the incriminated appendix has had.
Aside from what may concern the appendix itself the two most serious complicating local conditions are _abscess_ and _gangrene with perforation_. Abscess is not necessarily the result of perforation, at least at first, but may be due to infection by continuity, the sequence of events being acute appendicitis, with exudation, fixation, and adhesion of surrounding tissues, followed by pus formation, perhaps first within the appendix and then perforating, or perhaps having its origin in the infected exudate exterior to it. So long as this process is localized by a protective barrier of surrounding lymph, with intestinal adhesions and the assistance of the omentum, there is to be dealt with a more or less complicated _peri-appendicular abscess_, such as in the past was frequently seen and spoken of as _perityphlitic_. Concerning the frequency of perityphlitic abscess in days gone by the literature of the previous century will afford ample illustration, but in spite of the surgical acumen and advice of Willard Parker, who taught the profession how to deal with it, its proper explanation did not come until the researches of Fitz, alluded to at the beginning of this chapter. Even now it is perhaps not quite correct to say that every typhlitic abscess, _i. e._, every collection of pus around the typhlon or head of the large intestine, is of appendicular origin, for the tendency has been to forget the possibility of phlegmonous cellulitis about any part of the bowel without reference to the appendix.
Such a peri-appendicular abscess may be small, containing but a few drops of pus, or extensive, even to the degree of holding a pint or more. The pus is usually offensive and sometimes one will find floating in it shreds of tissue, or even a completely separated and sloughed-off gangrenous appendix. According to the original location of the appendix, and the disposition of the adjoining parts, such a collection of pus may form a tumor in the iliac fossa, which may also fill the pelvis, or may present in the loin, closely simulating a perinephritic abscess.
It is unfortunate when the natural walling off process has failed and we have to deal with a _spreading, generalized, septic peritonitis_. A partial compromise between these conditions sometimes appears as a widespread yet practically localized peritonitis, in which several loops of bowel have become affixed, and, what is worse, infected to such an extent that they are themselves breaking down, so that there may be impending or actual gangrene of the intestine. Such a condition bespeaks the intensity of the infection and the destructiveness of the infectious process, and produces a condition which may appall the operator. The result is not only acute obstruction of the bowel but such a local condition that one scarcely knows where to begin or terminate his operative efforts. It was in such a case as this that I removed eight feet and nine inches of bowel, the last nine inches including the colon, turning in both ends and making a lateral anastomosis, because of multiple gangrenous patches, each of which taken alone would have required a distinct and laborious intestinal resection, it seeming better to remove the entire amount involved. This patient recovered and was well years after the operation. Still other complications may disturb the surgeon’s calculations. Thus _fecal fistula_ may have already occurred, or _suppurative thrombophlebitis_ may have already produced the beginnings or an _hepatic abscess_, while septic expressions within the lungs, the heart, or elsewhere may have also occurred. In addition to this general peritonitis, with all of its terrors, may put a hopeless aspect upon the case.
=Treatment.=--Viewed in the above light it will be seen that _appendicitis is essentially a surgical disease_, and that while mild attacks may at times be successfully conducted to resolution, or tend in that direction without treatment, the danger of spreading infection with all its possible disasters is ever present, and even a mild case is at no moment free from the danger of becoming acute. Considering its widest relations, and believing in the greatest good to the greatest number, the surgeon may easily maintain that, _save when it is too late, it is never a mistake to operate_, providing operation be properly performed. This, however, is sometimes out of the question, and the laity occasionally assume responsibility for a decision against the better judgment of the profession. We have to accept, then, the fact that, no matter what the theory may be, we are not always allowed to operate when we desire. Nevertheless if a universal rule could be established it could be laid down in terms such as these, that more lives would be saved by operating upon every case of appendicitis as soon as the diagnosis has been made or even in the presence of good reason for suspicion.
With conditions such as they are, and the fact that these cases are usually first seen by general practitioners whose surgical judgment has not been cultivated, and whose prejudices often actuate them, it may be said that every case should be seen early by a surgeon, no layman and no ordinary practitioner of small experience being in position to assume responsibility for delay. It then remains for the judicious and competent operator who may see such a case early, as thus advised, to study it carefully in order to convince himself whether there be about it good and sufficient reasons for not operating. The most honest operator does not gainsay the possibility of mild cases recovering without operation. He does, however, question by which course they run greater risk.
The following may serve as a brief summary of conditions which justify waiting:
1. When symptoms are mild and not increasing in severity;
2. When pain and tenderness are not pronounced and gradually subside;
3. When the pulse rate does not exceed 100;
4. When temperature is not rising nor showing abrupt changes, especially if during the first thirty-six hours there have been no rise. (Murphy states that if there has been no temperature during the first thirty-six hours he begins to doubt the diagnosis.)
5. When the belly is not distending;
6. When rigidity is not increasing and there is no evidence of peritonitis;
7. When nausea is not increasing;
8. When neither in facial expression nor elsewhere are there evidences of septic infection;
9. When there is no perceptible tumor in the right iliac fossa.
Under the above conditions the conservative surgeon will be justified in waiting; being prompt, however, to intervene, should there be change for the worse in any one of the features specified. Even here it may be said that with conditions all as favorable as above represented pus may be present (in small quantity) and the whole picture may suddenly change into one of local disaster.
Finally it may be summed up in these words: _When there is no doubt as to the advisability of waiting, then wait; but in case of doubt operate_, i. e., _give the patient the benefit of the doubt_, which he in this way the more certainly obtains.
=Non-operative Treatment.=--While thus waiting in cases which justify it, what should be done? Absolute rest in bed, even to the extent of using bedpan instead of commode, is the first essential. The second comprises abstention from all food, and practically the temporary starvation of the patient, who may be allowed water in abundance and nothing else. Altogether too much stress has been placed upon the so-called starvation treatment as “saving patients from operation.”
## Active therapeutic treatment is limited mainly to the use of cathartics
and of anodynes, according to reason therefor. On one hand it is not advisable to rudely stir up the large intestine, one part of whose structure is already involved in a serious and questionable inflammatory process; on the other hand it is not for the general welfare of the patient to permit him to continue with a condition of coprostasis and the ever-increasing stercoremia which it encourages. On the whole it would seem better to clean out the lower bowel at the earliest possible moment, after which if the patient be properly starved there will be less necessity for subsequent active catharsis. The question of anodynes is one of equal importance. Those who bear pain badly, or those who suffer intensely, will demand anodynes, which every physician knows both help to mask the symptoms and interfere with elimination; but such cases seem to be of themselves so violent that the extreme expression of pain should of itself be regarded as an indication for operation. It should be held, then, that cases which demand opiates for relief of pain demand operation even more strongly. In the mild cases, expectantly treated, the local application of ice may be of some value. In effect these cases are to be treated expectantly, and, while expectant treatment is a confession of weakness or of ignorance, it may be unavoidable because early operation is flatly refused.
=Indications for Operation.=--Sufficient reasons for not operating being absent or having passed, the following may be considered among the more urgent indications for immediate surgical attack:
1. Continued and especially increasing pain and tenderness;
2. A rapid pulse (110 or over) tending to increase in rapidity;
3. Any rapid change in the temperature, either a sudden rise or a drop to the normal or subnormal, without corresponding improvement in every other particular;
4. Increasing or widespread abdominal rigidity; when the right side of the abdomen of a sensible and non-neurotic subject is rigid this of itself should be sufficient to justify operation;
5. The appearance of tumor in the right iliac fossa;
6. Recurring and especially constant vomiting;
7. Any indication of septic infection, local or general.
Such are the indications by which the surgeon may say upon the instant of their recognition that a given case requires immediate operation. Fortunate are both he and the patient if the case be seen early, when these conditions have but lately shown themselves, and before it be too late. It has been said that almost _every death from appendicitis means the loss of a life that might have been saved_ and for which someone is responsible, this responsibility being divisible among the patient, the parents or family, and the general practitioner who first saw the case and was tardy in recognizing its essential features. While patients die after late operations the surgeon himself is rarely censurable, it not being his fault that he was called in too late, and the patient dying of the progress of the disease in spite of an operation and not because of it.
_Operation for appendicitis_ may be one of the simplest and easiest of the abdominal operations, especially when the acutely infectious element be not present, or it may be one of the most trying and difficult of all possible surgical procedures, taxing alike the judgment of the experienced operator and the resources of the clinic. Much will depend upon the time at which it is performed. If within the first forty-eight hours the surgeon may expect to find but a small amount of pus; if from the second to the fifth day, he may find a well-marked collection, while later he may have not only localized abscess but extensive complications. Again, he who operates between attacks, during the interval or interim stage, will find conditions of adhesion and results of old disease rather than its active products.
These operations should then be considered under these different headings:
1. Early operations in acute cases, where there is little or no tumor;
2. Operations in cases where abscess is present;
3. Operations in cases of more or less peritoneal involvement, with obstruction;
4. Interval operations.
Under the above headings conditions vary so widely that they can scarcely be spoken of or described under the same name. The seat of the disease should first be approached. Here there is wide range for choice of location of incision and even the method of its performance. Some prefer the outer border of the rectus, others go through the rectus muscle proper by an incision parallel to its fibers, which when exposed are separated, its sheath both anteriorly and posteriorly being divided separately. Others go through the abdominal wall by incisions more or less oblique, and made near the anterior superior spine, where are found the different layers of the abdominal muscles arranged in proper order, their fibers being disposed at right angles to each other. That incision is best in each case which affords the shortest and easiest route to the site of the lesion when it can be located. If tumor be present it is ordinarily best to go in directly over it. In the absence of tumor the point of greatest tenderness is the best guide. The possibility of subsequent hernia at the site which is weakened by operation should be taken into account. If it be possible to avoid drainage hernia may usually be avoided. When drainage is necessary hernia is sometimes unavoidable. The advantage of operation through the rectus is that the muscle fibers can be separated without dividing them. Incision here may, however, carry the operator so far from the site of the appendix that he must necessarily disturb the interior arrangement more than is advisable, and thus increase the danger of infection. The oblique exterior incisions near the ilium always permit of separation of the fibers of the external oblique. The deeper muscle fibers which cross at nearly a right angle may sometimes be nicked and widely separated by firm traction, as in the so-called “gridiron method,” or they may require division. A short external incision is desirable when it suffices for the purpose. Considerations of safety (_i. e._, the better exposure and easier removal of the appendix) may call in some instances for long incisions, and they should be made sufficiently long for his purpose.
It will often happen that as the surgeon passes more deeply toward the peritoneum he will find the tissues more or less edematous. This is a reliable indication of the presence of pus beneath, and should make him open the peritoneum with care and then use extreme caution in his further manipulation, lest by separating recent adhesions he permit pus to escape. The peritoneum being opened sufficiently the finger is gently insinuated, and thus the first orientation concerning internal conditions is obtained. With the exploring finger there should be ascertained, first, the existence of any adhesions; second, their location and relative firmness, and, third, in a general way, the amount of surrounding disturbance. With an appendix placed anteriorly we may thus come directly upon it, while when placed deeply and posteriorly we may have much to do before reaching it. After the first general exploration the next procedure should be to protect and wall off the region involved from the rest of the abdominal cavity by strips of gauze. These should be long and so secured that none may be lost by being left within the abdomen. The introduction of gauze for this purpose will sometimes increase depression and decrease blood pressure, but it is a necessary procedure in nearly every instance. Moreover, several strips may be needed, and the incision may have to be extended to a limit of two or three inches, according as further exploration reveals a more complicated situation. The fluid pus which may escape should be gently removed with dry gauze, or, if present in considerable amount, be carefully conducted toward the surface. Loops of bowel or tissue bound together by lymph should be gently separated, as they may easily tear, or since imprisoned between them there may be found small collections of pus. If found gangrenous the situation is thereby seriously complicated, and it is advisable not to restore such a loop to the abdominal cavity.
The omentum, as already indicated, may serve as a valuable guide to the location of the appendix, which may be found wrapped within it. It should be handled with great caution, while, at the same time, it is made to reveal the desired information. When the omentum is infiltrated, contorted, and adherent we may be sure of finding pus concealed within the cavity which it helps to wall off. That which is already gangrenous should be removed, with use of sutures in such a way that there shall be no subsequent bleeding. It may be found easily, or not until many other details have been mastered. The involved appendix, when found, may be in one of the conditions described above, all of which demand its removal save those where this has been already accomplished by violence of the disease, in which case the opening in the cecum may have to be closed, or one may employ it for the purpose of an artificial anus. The appendix is often so hard to find that any reliable guide will be welcomed. Such a guide may be found, first, in the location and relation of the omentum, and, secondly, in the cecum if this can be exposed, or in either one of its firm, longitudinal, white tissue bands, which, leading down on either side of the colon, meet and blend at the point of origin of the appendix. Either of these followed in the right direction leads to this spot. Conditions may be such, however, as to obscure both of these guides, and then the colon should be followed downward toward the ileocecal valve, or the small intestine up toward it, in the belief that in this vicinity, and probably in the centre of the tumor, the appendix will be found. What the surgeon shall next do depends on the details of each case. He has not only to remove the diseased appendix, but to ligate and separate from it its mesentery; furthermore to separate either or both of these from surrounding tissues or organs, _e. g._, the wall of the pelvis, the ovary, the bladder, the retroperitoneal tissue above the sacrum, or from the lateral or anterior abdominal wall. This separation may be easy, or in its performance the tube may rupture and both pus and fecal matter escape; or perforation may have already occurred and the operator will be conducted into a cavity containing matter, pus and fecal mixed, in which perhaps fecal concretions of considerable size will be found loose. He is fortunate who, finding a condition of this kind, finds at the same time that he is still within a circumscribed cavity. This he should respect, and, while endeavoring to clean it thoroughly and drain it, he will avoid doing further harm by breaking down its walls.
Another condition which may arise after the peritoneum is opened is that of escape of a quantity of seropurulent fluid or of almost clear pus which is free within the abdominal cavity. There may be little or much of this. When present it should be removed by gentle sponging before the gauze packing is introduced. Some operators are inclined to irrigate freely and endeavor to wash out all this contained fluid. Others are opposed to this method and believe that gentle dry sponging is preferable. When the appendix is found free and movable, and when the tissues in previous contact with it are free from evidences of destructive infection (as, for instance, when peritoneal surfaces have not lost all their glimmer or sheen), one should carefully remove it, cauterizing its stump, burying it beneath the surrounding peritoneum, and close the abdomen without drainage. In spite, however, of the assertions and actions of some operators, I believe it to be the wisest rule to lay down for general application that it is safer to drain in every case where free pus or breaking down exudate is discovered.
The _question of drainage_ thus raised is as important as any connected with this subject. When and how shall one drain is a question upon which hundreds of pages have been written by various operators, and one which, while settled for individuals, can hardly be settled for the profession at large by any brief statement. Inefficient drainage is almost as bad as none. Efficient drainage may call for the insertion of a tube into the depths of the pelvis, even for counteropening in the cul-de-sac, or for additional opening in the loin, or for the employment of two or three tubes and drains of various kinds. A large tube loosely packed with gauze, perhaps split through its length and abundantly provided with openings, is probably the most effectual drain for most purposes. The cigarette drain, of gauze wrapped in oiled silk, or a few folds of oiled silk loosely tied together, along which fluid may percolate, may be sufficient for cases of lesser extent. Large foul cavities are better left more widely open, and abundantly drained with gauze packing, in spite of the humorous stigma which has been cast upon some of these methods by Morris with his expression “committing taxidermy upon patients.” The depressing reflex influence of such packing being readily conceded it may be regarded as the lesser of two evils.
Another almost equally important question is that of _treatment of the peritoneal cavity_ when involved. Here methods and opinions have varied widely. A peritoneal cavity once inflamed cannot be made absolutely clean in any way, and much reliance should be placed on the properties of the membrane itself, which, to a large extent, should act as its own scavenger. When, however, by removing the parts evidently diseased we have taken away the main source of infection we may feel like relying upon the natural protective forces of the human body; still even here opinions differ. Thus some would flush the abdomen with hot saline solution and even leave some portion of it there, closing the external wound, while others would carefully avoid the introduction of anything by which infectious material may be spread; and while each method has much to justify it one is scarcely found preferable to the other. I believe, however, in thoroughly cleaning out any distinct abscess cavity, and if the pelvis be such then I would irrigate it. I would also thoroughly drain it.
The attention of the reader is here directed to the general considerations found earlier in this work concerning the general technique of abdominal operations, and the matters of drainage and after-care, it being scarcely necessary to reiterate what has been there said regarding the general use of saline solution locally and by the rectum, the advantage of the Fowler position, or of Murphy’s method of slow and gentle introduction of saline solution into the rectum, providing for its continuous absorption, etc.
The possibility of appendicitis leading to general peritonitis, this to acute obstruction of the bowel, and this possibly even to multiple gangrene, has been mentioned. What should best be done under these circumstances must depend upon the patient and upon the surroundings. With a patient too much reduced to justify any prolonged operation the surgeon would probably content himself with evacuation of pus which may be readily reached, and then perhaps by the formation of an artificial anus. Cases which will justify such extensive operation as that above reported by myself in this connection, where it was possible to successfully remove nearly nine feet of intestine, will be exceedingly rare, as well as impracticable in the ordinary private house.
A condition perhaps a little less serious but always perplexing is that of _gangrene of a limited area of cecum_ around a gangrenous appendix. To remove the appendix alone in this condition is to accomplish nothing, while to meet the indication may require the exsection of a small area of cecal wall or the resection of the entire cecum, or perhaps in cases of limited extent the enfolding of the gangrenous area and the suture of its edges in such a manner that when it sloughs it may slough into the bowel cavity.
When the surgeon sees a case of peri-appendicular (the old perityphlitic) abscess late, and after it is easily recognized, he should operate according to the local indication, making incision perhaps short and placing it at a point where pus will apparently be most easily reached and best drained. Most of these instances present rather on the side or even in the loin behind the colon, and here a posterior incision might be sufficient. This may here be more liberal, since there is little danger of postoperative hernia, while through it one may possibly expose the cecum freely and often reach even the appendix itself. In making this opening it is well, if possible, to separate the fibers of the transversalis by blunt dissection. Here, as in all of the other incisions made toward the outer side of the body, the opening should be made, if possible, obliquely and parallel to the branches of the iliohypogastric nerves, which are thereby avoided and loss of sensation thus prevented. In fact this posterior method is sometimes even more rapid, and preferable in exceedingly fat patients, while it will always cause less shock and abdominal distress than does an anterior section; moreover, drainage takes place in the most desirable direction.
_Fecal fistula_ is sometimes the immediate and unavoidable, sometimes a more or less delayed and apparently inevitable, result or complication of some of these operations. In the former instance it will be because of more or less gangrene or the necessity for an immediate enterostomy. In the latter case it results from conditions which are concealed, but may be imagined, comprising the giving way of tissues already compromised or else being a continuation of the ulcerative or gangrenous process. These complications are always unpleasant and untoward, though they rarely reflect upon the method or judgment of the operator, being essentially inevitable. If only the fecal outflow escape externally the condition may be regarded as inconvenient and temporary. Only in those instances in which the peritoneal cavity is contaminated does septic peritonitis ensue. The majority of these fecal fistulas close spontaneously by granulation tissue. Sometimes closure is rapid, sometimes delayed, in which latter case it may be stimulated by the use of silver nitrate, as already indicated above. In a few instances the condition is so extensive or so permanent as to justify or require further operation, which may be in the nature of a curettement of the fistulous tract, a slight plastic procedure, including a buttonhole suture about the opening, or possibly a complete intestinal resection. I have seen small, fistulous tracts discharge occasionally, even for years, and then finally close spontaneously, and have far oftener seen some form of spontaneous closure than necessity for operative intervention. The danger of infection around any such fistulous tract is ever present, and when it has occurred the fact will be made known by increase of edematous granulations, with swelling and tendency to breaking down. In every such case active cauterization, or, better still, the use of the curette, will be required.
A _tuberculous form of chronic appendicitis_, as well as tuberculous infection of a subacute exudate, is possible, the case being converted into one of greater chronicity, with more or less mild but constant septic features (hectic). In any event, so soon as the tuberculous element can be recognized radical measures should be instituted.
[Illustration: FIG. 583
Omentum being gently lifted in order to uncover the appendix enclosed with its fold. (Lejars.)]
[Illustration: FIG. 584
Appendix delivered from the abdominal cavity and brought to view. (Lejars.)]
[Illustration: FIG. 585
Separation of the meso-appendix. (Gosset.)]
=Operation for Chronic or Recurring Appendicitis; Internal Operations.=--Other things being equal the most favorable time at which to remove the appendix is that when pathological processes are least
## active. If, therefore, there be a choice the interval of quiescence
rather than the stage of active infection would be chosen. Interval operations, so called, are usually comparatively simple, both in principle and technique. There are times, however, when it is difficult to find a partially obliterated appendix which has been covered up in thickened peritoneum or partially organized exudate. In such a case considerable blunt dissection or separation may have to be done before it can be removed. In those instances is this particularly true where it had originally a retroperitoneal location, and at no time a free or movable position. When difficult of recognition we may be unerringly led to it if we but follow the bands of white fibrous tissue on either side of the cecum to their junction.
The opening by which the appendix should, under these circumstances, be reached may again be made at the point of election, and should best be located over the area of greatest tenderness. Whatever incision is selected we should endeavor to separate muscle bundles as much and incise as little as possible. The appendix being delivered through the wound, either before or after ligation of its mesentery, and being thus completely isolated, is removed close to the large intestine, its base being tied and its structure being seized within the blades of a forceps in such a way that none of its contents may escape. The scissors with which it is divided are contaminated by its contents and should not be used again until cleansed. The stump on the proximal side may be touched with the actual cautery, or scraped and then cauterized with pure carbolic acid or formalin solution in order to thoroughly disinfect it. Subsequent treatment of this stump differs with different operators. Some are satisfied to leave it thus cauterized, while others cover it with the adjoining peritoneum, which is brought together over the stump end by either a purse-string or a continuous suture. Yet others have been satisfied to invert the ends of the stump into the cecum and thus leave it with or without further protection. It seems to make really very little difference how the stump is treated, providing only it be disinfected and prevented from leaking. Nevertheless it would appear preferable to give it at least a peritoneal covering to prevent adhesions (Figs. 583 to 588).
[Illustration: FIG. 586
The base of the appendix is tied with silk. The meso-appendix is being tied in sections with the Cleveland needle. (Richardson.)]
[Illustration: FIG. 587
Appendix surrounded with ligature at its base, after its isolation from its mesentery. Purse-string suture in place. (Gosset.)]
[Illustration: FIG. 588
Complete detachment of appendix. (Gosset.)]
In the subsequent closure of the external wound drainage is not made, there having been no pus to call for it; while the more perfectly the wound layers be closed, each with a row of chromicized catgut sutures, the peritoneal incision being first carefully approximated and over it the muscle and aponeurotic layers, each by itself, the less the tendency to subsequent postoperative hernia. On general principles, also, the shorter the incision the less the danger of this undesirable event. Nevertheless other considerations should not be sacrificed to shortness and beauty of the cutaneous scar.
The essentials of after-treatment of these cases have been already summarized in the previous section, and to these little exception may be taken in cases such as those above described. Every precaution should be taken to prevent vomiting, as every muscular effort involved in the act tends to disturb a freshly sutured wound. While violent muscular efforts of defecation are also to be deprecated, there is perhaps as much or more to be dreaded from the abdominal distention which may result from inattention to free intestinal elimination. Until the bowels have been moved it is best to restrain the diet to the simplest fluid nourishment. So soon as elimination becomes free more liberality in diet may be allowed. There is the same liability to and danger from other possible complications, such as postanesthetic pneumonia, anuria, or lack of expulsive power of the bladder, which requires the use of the catheter, in these as in other abdominal cases. Principles of treatment, however, do not vary, and the reader is referred to the previous section already indicated.
_Paratyphlitic abscesses_ are to be distinguished from perityphlitic or peri-appendicular abscesses in that they arise from a phlegmonous process in the cellular tissue around the colon not due to intra-appendicular infection. In consequence of such a cellulitis more or less considerable collections of pus may form, which are most likely to present either in the loin or just in front of the cecum, which may burrow either upward or downward, or appear elsewhere. They are mentioned here, not because they are to be differently treated or surgically regarded, but because it is worth while to remember that here about the cecum and ascending colon, as on the left side, such pericolic abscesses may form without reference to the appendix.
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