Chapter XLIX: The Appendix and Its Diseases.59 (2)

=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.

Omentum being gently lifted in order to uncover the appendix enclosed with its fold. (Lejars.)]

Appendix delivered from the abdominal cavity and brought to view. (Lejars.)]

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).

The base of the appendix is tied with silk. The meso-appendix is being tied in sections with the Cleveland needle. (Richardson.)]

Appendix surrounded with ligature at its base, after its isolation from its mesentery. Purse-string suture in place. (Gosset.)]

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.