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Management of the desperate appendicitis case
MANAGEMENT
OF THE DESPERATE APPENDICITIS ARVID
C.
CASE*
SILVERBERG, M.D.
Visiting Surgeon, King County HospitaI
SEATTLE, WASHINGTON
I
F we are unreservedIy to believe the statistics on appendicitis mortahty we find that there has been a decided increase during the Iast thirty years. However, the statistics seem to be whoIIy unreliabIe because deaths due to appendicitis were formerIy often not reported as such, but simpIy as peritonitis or intestina1 obstruction. This is now no Ionger the case; the origina appendicitis, listed as the cause of death, brings about an apparent increase in frequency. The changing mode of Iiving shows a definite tendency to increase the appendicitis incidence. A thorough statistical survey conducted in Germany covering the years of 19x0 to 1929 shows that in a popuIation of approximateIy 63,000,000 in rgro there were 3;826 deaths from appendicitis in 48,996 cases. During the years of the war there was a gradua1 decrease of appendicitis deaths as we11 as a decrease in the number of appendicitis cases diagnosed. This was ascribed to more restricted diet and a more simple mode of living. By rg2g when the population of Germany was the same as in rgro the deaths from appendicitis were 5,721 in 2 10,512 cases. The statistics aIso cover the frequency of appendicitis in the rura1 districts and in the cities, showing that the frequency in the cities is more than a hundred times greater. Evidently appendicitis is a disease of higher civiIization, where occupations are more sedentary. The five-foId increase in frequency with onIy a twofoId increase, or Iess, in the death rate iIIustrates the more efficient surgica1 treatment and perhaps the tendency to greater morbidity in a country with state medicine. We may aIso bIame the physicians. Many of us are ahogether too wiIIing to * Read before the Seat&
pIease the patient and appIy the icebag or heat and adopt a watchfu1 waiting attitude. We know that many cases of appendicitis subside, but shouId another member of the famiIy or the same patient have another attack, the same treatment wiI1 be appIied and the resuIt may be an appendicitis which proceeds to perforation. There is no doubt that an increase has occurred in the number of appendicitis cases which go on to gangrene and perforation, due to ‘deIay in seeking competent medica and surgical advice. In the Pacific Northwest, the prevalence of cuIts and faith heaIers is to a great extent to blame. This has forcefuIIy been brought to my attention IateIy, as iIIustrated by the foIIowing two cases. CASE I. A girl, 20 years oId, was seized with vomiting and abdomina1 pain. She went to a chiropractor who treated her with, <‘spina adjustments,” and massage over the abdomen for days. A surgeon was caIIed and diagnosed the case as ruptured appendix with an abscess, and a secondary rupture of the abscess into the peritonea1 cavity. CASE II. A man 30 years of age developed abdomina1 pain, had a chiropractic treatment the foIIowing day, and took cathartics. On the seventh day the abdomina1 pain became so severe that he couId no Ionger bear it and he then summoned me. I found a buIging over the right Iower quadrant and rigid abdomina1 muscIes. He was brought to the hospita1 and operated on, the incision being made over the abscess which was found to have ruptured into the abdomina1 cavity. The intestines were bathed in thin, whey-Iike pus. On the second day gas baciIIus infection in the abdomina1 waI1 became apparent. Death resuIted from toxemia produced by the gas bacillus infection.
Academy
92
of Surgery,
February
21,
1936.
NEW- SERIES VOL. XLIII.
No. I
SiIverberg-Appendicitis
In an editorial1 in Surgery, GynecoIogy and Obstetrics, the statement is made that, “To operate in a case of spreading peritonitis invites catastrophe.” The writer compares the condition with a skin or a subcutaneous progenic infection where the process is aIIowed to become IocaIized and waIIed off before an incision is made for drainage. He states that the management of genera1 peritonitis is identical. It seems to me, however, that where we have a hoIIow viscus that becomes distended at the shghtest provocation and especiaIIy when we have a peritonitis foIIowing a ruptured appendix, the thing to do is to relieve the distention and remove the cause if possibIe. It is important to reestabIish the circulation as soon as possible, certainIy before a paraIytic iIeus deveIops. Gurd” states that, “the teaching, that the risk to the patient may be minimized by postponement of operation in the hope that a safe period may deveIop is to be condemned.” My experience with a comparativeIy smaI1 series of cases leads me to beIieve that the postponement of the operation has very IittIe in its favor. Draining an abscess and Ieaving the appendix in situ in seIected cases is to be recommended. However, to do this as a routine wiI1, I beIieve, cause an increase in the mortaIity rate and generaIIy require reoperation. I have seen cases in which, years after drainage, appendicea1 abscesses deveIoped and caused death. If nature has faiIed in its attempt to overcome the infection, if the appendix has ruptured, and abscess formation or spreading peritonitis or both have occurred, the best thing that can be done is for the surgeon to assist nature in its fight. From externa1 examination it is aImost impossibIe to teI1 the extent of the peritonitis. Everyone who has done any considerabIe abdomina1 surgery has made an incision in the upper abdomen or in the midIine beIow the umbiIicus, expecting to find the Iesion there, onIy to find, to his surprise, an uninvoIved peritonea1 cavity in this Iocation.
American
Journal
of Surgery
93
Instead there will be a ruptured appendix in the right Iower quadrant. Many such cases, treated medicaIIy as generaIized
FIG. I. Diagrammatic representation of the enterostomy tube in Case III. Where the tube is used for intestina1 decompression in cases of gangrenous appendicitis with spreading peritonitis, the tube enters the cecum and ascending colon onIy.
peritonitis and reported as recovered, were in reaIity instances of circumscribed appendicea abscesses, which may have ruptured into the cecum and drained themseIves. There is onIy one way to treat appendicitis -earIy diagnosis and immediate operation. In deaIing with appendicitis which has deveIoped into gangrene with peritonitis of varying extent, it is desirabIe to achieve a method of treatment which results in the smaIIest possibIe mortaIity and we fee1 that this IS best done by aiding nature in its fight against the invading infection. In the abdomina1 cavity we find an easily distended viscus, whose distention cuts off the circuIation to the intestina1 waI1 by compression of its vessels. We can thus aid nature by defIating the viscus. The peritoneum has great power of withstanding and IocaIizing any foreign invasion if there is no interference with circuIation. My method is to insert a No. 22 catheter through the appendix stump. If there is
94
American Journd of Surgery
Silverberg-Appendicitis
much invoIvement at the base of the appendix, it is removed in the usuaI manner and another site on the cecum is used for the enterostomy. Where the appendix stump is being utilized, the catheter is fastened to it with a catgut suture. A pursestring suture is applied about the base of the appendix; it is invaginated around the catheter and the purse-string suture tied. A piece of omentum is pIaced about the catheter, and the Iatter is brought out through a stab wound IateraI to the incision. The cecum may be anchored to the peritoneum. The enterostomy tube is fastened with silkworm gut to the skin. Adhesions which kink or bind down the bowe1 are reIeased. Packs are used to protect the peritonea1 cavity, if this can be done before the abscess is broken into. They are never put down through an infected area, since this mereIy heIps to spread the infection. Abscesses are drained with gauze. Drains are never passed into an uninvoIved portion of the peritonea1 cavity, and they are never pIaced in the pelvis if pus is not found there at the time of the operation. Peritonitis traveIs by continuity. The wound is cIosed in Iayers and the patient returned to the bed, where he is turned on his right side. The enterostomy tube is connected to a bottIe, as in gaIIbIadder drainage. I have aIways found this an effective means of keeping down the distention. The patient’s postoperative course is much easier. There are no gas pains; the toxic intestina1 contents are rapidly removed, and therefore there are fewer toxic manifestations. Since death in these cases is due to retroperitoneal infection and toxic absorption from the intestines, draining the intestines removes one factor. Administration of anaerobic antitoxin is aIso advisable. The postoperative treatment of acute appendicitis with complications consists of constant attention to detaiIs. Daily recta1 examination shouId be made. If abscesses deveIop, they shouId be drained through the rectum or, in women, through the posterior vaginal fornix. It is necessary to
watch out for subhepatic or suphrenic abscesses. Nothing is to be given by mouth, but intravenous saIine plus 5 per cent glucose shouId be administered as required, up to 3,000 C.C. a day. SubpectoraI or hypodermocIysis may have to be used if the condition demands. No soIution should be given per rectum and no enemas shouId be permitted. If there is gas in the distal portion of the colon, a recta1 tube may be inserted. Constant heat to the abdomen, maintaining the patient in a semi-prone position to the right, and gastric Iavage, if necessary, are vaIuabIe measures. Morphine may be given to avoid pain during the first few days. One must keep constant vigi1 to prevent complications from arising rather than to treat them after they have deveIoped. The detaiIs of treatments should not be entrusted to nurses or interns if they have not been especiaIIy trained. The surgeon owes it to his patient to attend to the postoperative care himseIf. CHART
Number of cases.. . . . . . . . Age range. ,.. . . Duration before operation. Incidence of gangrene, peritonitis and abscess. Gangrene and peritonitis with no Iocalization. . Gangrene and peritonitis with subphrenic abscess Miscellaneous Five months’ pregnancy. .
1
75 4 to 65 years 9 hours to 7 days
56 17 (I death) 2
I
(Smooth convalescence. Delivered at term of heaIthy baby.) (Died)
Gas baciIIus infection. I Postoperative complications Subphrenic abscess.. .. . 2 PuImonary abscess.. . Perinephritic abscess. . . . PeIvic abscess. .. ..... 7 MoraIity.. . . ... . 2.6 per cent
Chart I shows the findings in the series of cases here presented. The mortality rate is Iow; perhaps in a greater number of cases it would be increased severa times. There is no doubt that many surgeons object to the method of treatment advocated. Many men are deathIy afraid of feca1 Iistula-but a fecal fistula which is open to the outside adds nothing to the risk, and is definiteIy beneficia1. The
NFH SERIFSVOL.XLIII, No.
I
SiIverberg-Appendicitis
operative time is not much Iengthened by the enterostomy procedure, whiIe the easier postoperative course makes it certainIy worthwhile. No greater tendency to postoperative hernia is exhibited than in any other treatment with drainage. The fistuIa heaIs by itseIf, as a ruIe. (This has been true in a11 my cases. In one, a boy 9 years old, the cIosure took pIace in two months after the patient was home and again in good health.) The enterostomy method is not new, but I am convinced that Iives have been saved by it. In this smaI1 group of cases (seventy-five), a11 have been operated on immediately, or as soon as possibIe, after the diagnosis has been made. There has been no deIay or attempt to estabIish a safe period by Ochsner’s method or any other procedure. Where the appendix had not ruptured, or where abscesses or spreading peritonitis were not present, enterostomy was not done and the cases were excluded. There have been two deaths in the series. The foIIowing case (not incIuded in the series) iIIustrates the advantage of enterostomy and the ease with which it cIoses when properly performed. The acuteIy inffamed appendix in this case required no enterostomy, but there was obstruction with mesenteric thrombosis. The smooth and short convalescence in this serious case I attribute to the enterostomy. CASE III. A female, age 50, five years before had had what was supposed to have been an abscessed appendix which was drained. Her present iIIness began three days before admission with intermittent pain in the abdomen, which had graduahy become worse. There had been no bowe1 movements for two days. On examination, I found a moderately distended abdomen with visibIe peristalsis. There was a ventra1 hernia foIIowing the right rectus incision at the previous operation. The contents of the hernia1 sac couId easiIy be reduced, but this did not affect the symptoms. The temperature was IOO and the puIse go. -My diagnosis was an obstructed bowe1 due to adhesions.
American Journal of Surgery
94
The patient was brought to the hospital and an incision was made just media1 to the old scar. About 3 feet of the terminal ileum were found to be discoIored, edematous and caught in a tight band. The mesenteric veins to the same portion were thrombotic. The Iast few inches of the iIeum, were not involved. The appendix was free, but acuteIy inflamed. There were no signs of any previous invoIvement about the appendix. We did a resection of the ileum together with the mesentery containing the thrombotic veins. An end-to-end anastomosis was made to the terminal portion of the ileum and the appendix was removed. A No. 22 catheter was inserted through an enterostomy in the cecum, through the iIeoceca1 vaIve, and past the anastomosis. The hernia was repaired, The patient made an uneventfu1 recovery without distention or discomfort. The enterostomy tube was removed on the fifth day and the fistuIa was heaIed on the eighth. The patient Ieft the hospital in two weeks and has remained we11 since. SUMMARY I. The frequency of appendicitis is increasing with advance in civiIization. 2. Delay in seeking competent aid is the main factor in the mortahty rate and medica treatment shares a portion of this responsibiIity. 3. The inff uence of cuItism in the Northwest is aIs a factor. 4. Operative interference is recommended at time of diagnosis irrespective of the condition of the patient. 5. RemovaI of the appendix is necessary, with an enterostomy at the primary operation and drainage with gauze of the abscess cavities. 6. Antitoxin for anaerobic infection is administered in cases of ruptured appendix. 7. The right Iateral position is best for drainage. 8. CarefuI postoperative management is advised, with the surgeon taking persona1 charge and making daily examinations. REFERENCES I. Editorial, Surg., Gynec. Ed Ok. May, 1932. 2. CURD, F. B. Am. J. Surg., 17: 52, 1932. 3. MAYO, CHARLES W. Appendicitis. In Collected
Papers of the Mayo Clinic, 26: 154-162,
rg34.
OF THE DESPERATE APPENDICITIS ARVID
C.
CASE*
SILVERBERG, M.D.
Visiting Surgeon, King County HospitaI
SEATTLE, WASHINGTON
I
F we are unreservedIy to believe the statistics on appendicitis mortahty we find that there has been a decided increase during the Iast thirty years. However, the statistics seem to be whoIIy unreliabIe because deaths due to appendicitis were formerIy often not reported as such, but simpIy as peritonitis or intestina1 obstruction. This is now no Ionger the case; the origina appendicitis, listed as the cause of death, brings about an apparent increase in frequency. The changing mode of Iiving shows a definite tendency to increase the appendicitis incidence. A thorough statistical survey conducted in Germany covering the years of 19x0 to 1929 shows that in a popuIation of approximateIy 63,000,000 in rgro there were 3;826 deaths from appendicitis in 48,996 cases. During the years of the war there was a gradua1 decrease of appendicitis deaths as we11 as a decrease in the number of appendicitis cases diagnosed. This was ascribed to more restricted diet and a more simple mode of living. By rg2g when the population of Germany was the same as in rgro the deaths from appendicitis were 5,721 in 2 10,512 cases. The statistics aIso cover the frequency of appendicitis in the rura1 districts and in the cities, showing that the frequency in the cities is more than a hundred times greater. Evidently appendicitis is a disease of higher civiIization, where occupations are more sedentary. The five-foId increase in frequency with onIy a twofoId increase, or Iess, in the death rate iIIustrates the more efficient surgica1 treatment and perhaps the tendency to greater morbidity in a country with state medicine. We may aIso bIame the physicians. Many of us are ahogether too wiIIing to * Read before the Seat&
pIease the patient and appIy the icebag or heat and adopt a watchfu1 waiting attitude. We know that many cases of appendicitis subside, but shouId another member of the famiIy or the same patient have another attack, the same treatment wiI1 be appIied and the resuIt may be an appendicitis which proceeds to perforation. There is no doubt that an increase has occurred in the number of appendicitis cases which go on to gangrene and perforation, due to ‘deIay in seeking competent medica and surgical advice. In the Pacific Northwest, the prevalence of cuIts and faith heaIers is to a great extent to blame. This has forcefuIIy been brought to my attention IateIy, as iIIustrated by the foIIowing two cases. CASE I. A girl, 20 years oId, was seized with vomiting and abdomina1 pain. She went to a chiropractor who treated her with, <‘spina adjustments,” and massage over the abdomen for days. A surgeon was caIIed and diagnosed the case as ruptured appendix with an abscess, and a secondary rupture of the abscess into the peritonea1 cavity. CASE II. A man 30 years of age developed abdomina1 pain, had a chiropractic treatment the foIIowing day, and took cathartics. On the seventh day the abdomina1 pain became so severe that he couId no Ionger bear it and he then summoned me. I found a buIging over the right Iower quadrant and rigid abdomina1 muscIes. He was brought to the hospita1 and operated on, the incision being made over the abscess which was found to have ruptured into the abdomina1 cavity. The intestines were bathed in thin, whey-Iike pus. On the second day gas baciIIus infection in the abdomina1 waI1 became apparent. Death resuIted from toxemia produced by the gas bacillus infection.
Academy
92
of Surgery,
February
21,
1936.
NEW- SERIES VOL. XLIII.
No. I
SiIverberg-Appendicitis
In an editorial1 in Surgery, GynecoIogy and Obstetrics, the statement is made that, “To operate in a case of spreading peritonitis invites catastrophe.” The writer compares the condition with a skin or a subcutaneous progenic infection where the process is aIIowed to become IocaIized and waIIed off before an incision is made for drainage. He states that the management of genera1 peritonitis is identical. It seems to me, however, that where we have a hoIIow viscus that becomes distended at the shghtest provocation and especiaIIy when we have a peritonitis foIIowing a ruptured appendix, the thing to do is to relieve the distention and remove the cause if possibIe. It is important to reestabIish the circulation as soon as possible, certainIy before a paraIytic iIeus deveIops. Gurd” states that, “the teaching, that the risk to the patient may be minimized by postponement of operation in the hope that a safe period may deveIop is to be condemned.” My experience with a comparativeIy smaI1 series of cases leads me to beIieve that the postponement of the operation has very IittIe in its favor. Draining an abscess and Ieaving the appendix in situ in seIected cases is to be recommended. However, to do this as a routine wiI1, I beIieve, cause an increase in the mortaIity rate and generaIIy require reoperation. I have seen cases in which, years after drainage, appendicea1 abscesses deveIoped and caused death. If nature has faiIed in its attempt to overcome the infection, if the appendix has ruptured, and abscess formation or spreading peritonitis or both have occurred, the best thing that can be done is for the surgeon to assist nature in its fight. From externa1 examination it is aImost impossibIe to teI1 the extent of the peritonitis. Everyone who has done any considerabIe abdomina1 surgery has made an incision in the upper abdomen or in the midIine beIow the umbiIicus, expecting to find the Iesion there, onIy to find, to his surprise, an uninvoIved peritonea1 cavity in this Iocation.
American
Journal
of Surgery
93
Instead there will be a ruptured appendix in the right Iower quadrant. Many such cases, treated medicaIIy as generaIized
FIG. I. Diagrammatic representation of the enterostomy tube in Case III. Where the tube is used for intestina1 decompression in cases of gangrenous appendicitis with spreading peritonitis, the tube enters the cecum and ascending colon onIy.
peritonitis and reported as recovered, were in reaIity instances of circumscribed appendicea abscesses, which may have ruptured into the cecum and drained themseIves. There is onIy one way to treat appendicitis -earIy diagnosis and immediate operation. In deaIing with appendicitis which has deveIoped into gangrene with peritonitis of varying extent, it is desirabIe to achieve a method of treatment which results in the smaIIest possibIe mortaIity and we fee1 that this IS best done by aiding nature in its fight against the invading infection. In the abdomina1 cavity we find an easily distended viscus, whose distention cuts off the circuIation to the intestina1 waI1 by compression of its vessels. We can thus aid nature by defIating the viscus. The peritoneum has great power of withstanding and IocaIizing any foreign invasion if there is no interference with circuIation. My method is to insert a No. 22 catheter through the appendix stump. If there is
94
American Journd of Surgery
Silverberg-Appendicitis
much invoIvement at the base of the appendix, it is removed in the usuaI manner and another site on the cecum is used for the enterostomy. Where the appendix stump is being utilized, the catheter is fastened to it with a catgut suture. A pursestring suture is applied about the base of the appendix; it is invaginated around the catheter and the purse-string suture tied. A piece of omentum is pIaced about the catheter, and the Iatter is brought out through a stab wound IateraI to the incision. The cecum may be anchored to the peritoneum. The enterostomy tube is fastened with silkworm gut to the skin. Adhesions which kink or bind down the bowe1 are reIeased. Packs are used to protect the peritonea1 cavity, if this can be done before the abscess is broken into. They are never put down through an infected area, since this mereIy heIps to spread the infection. Abscesses are drained with gauze. Drains are never passed into an uninvoIved portion of the peritonea1 cavity, and they are never pIaced in the pelvis if pus is not found there at the time of the operation. Peritonitis traveIs by continuity. The wound is cIosed in Iayers and the patient returned to the bed, where he is turned on his right side. The enterostomy tube is connected to a bottIe, as in gaIIbIadder drainage. I have aIways found this an effective means of keeping down the distention. The patient’s postoperative course is much easier. There are no gas pains; the toxic intestina1 contents are rapidly removed, and therefore there are fewer toxic manifestations. Since death in these cases is due to retroperitoneal infection and toxic absorption from the intestines, draining the intestines removes one factor. Administration of anaerobic antitoxin is aIso advisable. The postoperative treatment of acute appendicitis with complications consists of constant attention to detaiIs. Daily recta1 examination shouId be made. If abscesses deveIop, they shouId be drained through the rectum or, in women, through the posterior vaginal fornix. It is necessary to
watch out for subhepatic or suphrenic abscesses. Nothing is to be given by mouth, but intravenous saIine plus 5 per cent glucose shouId be administered as required, up to 3,000 C.C. a day. SubpectoraI or hypodermocIysis may have to be used if the condition demands. No soIution should be given per rectum and no enemas shouId be permitted. If there is gas in the distal portion of the colon, a recta1 tube may be inserted. Constant heat to the abdomen, maintaining the patient in a semi-prone position to the right, and gastric Iavage, if necessary, are vaIuabIe measures. Morphine may be given to avoid pain during the first few days. One must keep constant vigi1 to prevent complications from arising rather than to treat them after they have deveIoped. The detaiIs of treatments should not be entrusted to nurses or interns if they have not been especiaIIy trained. The surgeon owes it to his patient to attend to the postoperative care himseIf. CHART
Number of cases.. . . . . . . . Age range. ,.. . . Duration before operation. Incidence of gangrene, peritonitis and abscess. Gangrene and peritonitis with no Iocalization. . Gangrene and peritonitis with subphrenic abscess Miscellaneous Five months’ pregnancy. .
1
75 4 to 65 years 9 hours to 7 days
56 17 (I death) 2
I
(Smooth convalescence. Delivered at term of heaIthy baby.) (Died)
Gas baciIIus infection. I Postoperative complications Subphrenic abscess.. .. . 2 PuImonary abscess.. . Perinephritic abscess. . . . PeIvic abscess. .. ..... 7 MoraIity.. . . ... . 2.6 per cent
Chart I shows the findings in the series of cases here presented. The mortality rate is Iow; perhaps in a greater number of cases it would be increased severa times. There is no doubt that many surgeons object to the method of treatment advocated. Many men are deathIy afraid of feca1 Iistula-but a fecal fistula which is open to the outside adds nothing to the risk, and is definiteIy beneficia1. The
NFH SERIFSVOL.XLIII, No.
I
SiIverberg-Appendicitis
operative time is not much Iengthened by the enterostomy procedure, whiIe the easier postoperative course makes it certainIy worthwhile. No greater tendency to postoperative hernia is exhibited than in any other treatment with drainage. The fistuIa heaIs by itseIf, as a ruIe. (This has been true in a11 my cases. In one, a boy 9 years old, the cIosure took pIace in two months after the patient was home and again in good health.) The enterostomy method is not new, but I am convinced that Iives have been saved by it. In this smaI1 group of cases (seventy-five), a11 have been operated on immediately, or as soon as possibIe, after the diagnosis has been made. There has been no deIay or attempt to estabIish a safe period by Ochsner’s method or any other procedure. Where the appendix had not ruptured, or where abscesses or spreading peritonitis were not present, enterostomy was not done and the cases were excluded. There have been two deaths in the series. The foIIowing case (not incIuded in the series) iIIustrates the advantage of enterostomy and the ease with which it cIoses when properly performed. The acuteIy inffamed appendix in this case required no enterostomy, but there was obstruction with mesenteric thrombosis. The smooth and short convalescence in this serious case I attribute to the enterostomy. CASE III. A female, age 50, five years before had had what was supposed to have been an abscessed appendix which was drained. Her present iIIness began three days before admission with intermittent pain in the abdomen, which had graduahy become worse. There had been no bowe1 movements for two days. On examination, I found a moderately distended abdomen with visibIe peristalsis. There was a ventra1 hernia foIIowing the right rectus incision at the previous operation. The contents of the hernia1 sac couId easiIy be reduced, but this did not affect the symptoms. The temperature was IOO and the puIse go. -My diagnosis was an obstructed bowe1 due to adhesions.
American Journal of Surgery
94
The patient was brought to the hospital and an incision was made just media1 to the old scar. About 3 feet of the terminal ileum were found to be discoIored, edematous and caught in a tight band. The mesenteric veins to the same portion were thrombotic. The Iast few inches of the iIeum, were not involved. The appendix was free, but acuteIy inflamed. There were no signs of any previous invoIvement about the appendix. We did a resection of the ileum together with the mesentery containing the thrombotic veins. An end-to-end anastomosis was made to the terminal portion of the ileum and the appendix was removed. A No. 22 catheter was inserted through an enterostomy in the cecum, through the iIeoceca1 vaIve, and past the anastomosis. The hernia was repaired, The patient made an uneventfu1 recovery without distention or discomfort. The enterostomy tube was removed on the fifth day and the fistuIa was heaIed on the eighth. The patient Ieft the hospital in two weeks and has remained we11 since. SUMMARY I. The frequency of appendicitis is increasing with advance in civiIization. 2. Delay in seeking competent aid is the main factor in the mortahty rate and medica treatment shares a portion of this responsibiIity. 3. The inff uence of cuItism in the Northwest is aIs a factor. 4. Operative interference is recommended at time of diagnosis irrespective of the condition of the patient. 5. RemovaI of the appendix is necessary, with an enterostomy at the primary operation and drainage with gauze of the abscess cavities. 6. Antitoxin for anaerobic infection is administered in cases of ruptured appendix. 7. The right Iateral position is best for drainage. 8. CarefuI postoperative management is advised, with the surgeon taking persona1 charge and making daily examinations. REFERENCES I. Editorial, Surg., Gynec. Ed Ok. May, 1932. 2. CURD, F. B. Am. J. Surg., 17: 52, 1932. 3. MAYO, CHARLES W. Appendicitis. In Collected
Papers of the Mayo Clinic, 26: 154-162,
rg34.