Prevention of late postoperative complications in acute suppurative appendicitis

PREVENTION

OF LATE POSTOPERATIVE

ACUTE SUPPURATIVE

COMPLICATIONS

IN

APPENDICITIS

WITH THREE CASE REPORTS*

JOHN J. MCGRATH, M.D., F.A.C.S. AND STANLEY EISS, M.D., F.A.C.S. NEW YORK

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PON Iooking over the vast Iiterature of appendicitis, one is at once impressed with the deep concern that is, not unnaturahy, feIt by surgeons for the mortality figures of this disease, which continue to be far in excess of what ought to be expected in an era when surgica1 technique has reached a refinement unknown to ear-her generations. WiIIis’sl figures in 1926 showed that appendicitis has been on the increase since rgoo, and that the number of deaths annuahy from this cause equals a11 those from saIpingitis, peIvic abscess, surgica1 diseases of the pancreas, spIeen and thyroid; gaIIstones and ectopic pregnancy put together. A recent United State’s Government report states that 20,000 individuaIs die annuaIIy in this country from appendicitis. It is evident that practitioners of the present day are not fuIIy awake to the dangers invoIved in deIaying appendectomy, or to the serious nature of the compIications resuIting from this negIect. This is borne out by the fact that FinIey2 in a recent review of 3913 operative cases of appendicitis found that even as recentIy as in the five-year period from 1926 to 18. r 7 per cent of cases 1930 incIusive, had ruptured before being operated on, causing that author to ask: “Is it not stiI1 a rather sad commentary that in aImost one of every five cases rupture has occurred when the patients reach the operating room?” Saving Iife must naturaIIy be the first concern of the surgeon. But saving Iife is not enough. Is it asking too much if * From the Department

of Surgery,

we demand that the patient who does not succumb during the course of an acute appendicitis shaI1 be restored to fuI1 heaIth and efficiency? To what extent do present methods of surgica1 treatment attain this idea1 end? In how many cases where Iife is saved are the patients forced to return for further operation after dragging through months of invaIidism resuIting from avoidabIe adhesions, IistuIae, recurrent appendicitis, secondary abscesses, intestina1 obstruction, infection of the abdomina1 waI1, and other compIications? As Lowe3 has so aptIy said, “some men think appendicitis is a simpIe thing, but in grave cases there is no surgica1 disease that requires greater nicety of judgment and skiII!” Not onIy are earIy diagnosis and operation caIIed for, but aIso inteIIigent judgment, the outgrowth of experience in executing the operation, if we are to see our patients compIeteIy cured, without the handicap of postoperative compIications that in many cases make Iife an intoIerabIe burden unti1 relieved. The purpose of this communication is to point out what we are convinced is a major cause of poor recoveries from appendicitis, resuIting in Iingering invaIidism, sIow toxemia, and in some cases unIess reIieved by secondary operation, in death itseIf, months or years after an incompIete operation. Many surgeons in doing appendectomy make it a practice, when they find pus, simply to drain, and leave the appendix alone. They pursue this course because

New York PoIycIinic II2

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they are afraid of spreading a IocaIized peritonitis. It is our hope to show here not onIy that there is no proper basis for such fears but aIso that there are certain grave dangers invoIved in the performance of anything short of a compIete operation when the abdomen is opened in a case of acute appendicitis. It is a very common thing for patients who have had an emergency operation for acute appendicitis to continue to compIain of disturbances in the iIeoceca1 fossa and right haIf of the abdomen, in cases in which the appendix has not been removed or in which the stump of the appendix has not been we11 cared for, resuIting in. pathoIogica1 rests of the inflammatory process which remain to give troubIe at a Iater time. An operation for appendicitis that does not remove the appendix is at bottom onIy a paIIiative one. As Montanari4 says, it may have an absoIute vaIue quoad vitam, but not quoad valetudinem. The abdomina1 cavity has been drained for a circumscribed peritonitis, but the patient has not recovered his heaIth to the extent of being abIe to resume his norma activities. Fresh attacks of acute appendicitis occur, or the patient suffers with chronic functiona1 disturbances that caI1 for secondary operation. Upon reopening the abdomen, what do we find? InvariabIy adhesions of inffammatory origin, in which the great omentum has become caught and permanentIy fixed, together with abnorma1 connections between the cecum, iIeum, coIon and other structures. EspeciaIIy do the cecum and ascending coIon suffer as the resuIt of a process of fibrous transformation, with a tendency to retraction, due to Iesions of perityphIitis and membranous pericoIitis. The very barriers that were formed by nature for protection in the course of a circumscribed suppurative peritonitis may become at a more advanced period the cause of serious compIications after they have undergone fibrous changes. At any rate it remains evident, as Montanari

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points out, that if it has not been possibIe to remove the appendix the Iatter wiI1 itseIf be capabIe of perpetuating the inffammatory process and of causing a fresh attack of appendicitis. CASE

REPORTS

The foIIowing three case histories wiI1 serve to iIIustrate the types of Iesions that may be expected to persist after an incompIete operation, and to force the patients to return for the reIief of intoIerabIe symptoms. CASE I. Case No. 3804. Baby B. P., aged three years, maIe, was admitted to the New York PoIycIinic HospitaI on June 25, 1932, with a provisiona diagnosis of acute recurrent appendicitis. The history given was that of an appendix which had ruptured in March, 1932, and which was at that time drained but not removed. Twenty-four hours previous to admission, the chiId was seized again with acute pains and on the foIIowing morning was brought to the hospita1 with secondary appendicitis. The attitude of the child’s reIatives made it impossibIe to obtain any further detaiIs of the history. At operation, which was performed immediateIy, the abdomen showed a right iIiac scar of recent incision for appendectomy. Incision was made through the outer side of the scar, and through the right rectus muscle. When the abdomen was opened, there was an escape of free pus from the abdomina1 cavity. The appendix was found buried in a mass of adhesions and a rather copious fIow of pus attended the bringing up of the organ into the incision. The pus was sponged away and the abdomina1 cavity packed off carefuIIy with gauze pads. The appendix was detached from the adjacent structures, its mesentery tied off, and a Iigature tied around the root of the appendix. In the process of drawing the Iigature tight and tying it, the diseased appendix was cut through; the suture, however, apparentIy heId the mucous Iining of the Iatter. The waI1 of the cecum for about I inch around the stump of the appendix was yeIIowish, friabIe, and appeared aImost ready to break down. This area of the waI1 was inverted and secured with a continuous suture of fine bIack siIk. The abdomina1 cavity adjacent to the

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fieId of operation was again sponged and a drain introduced into the abdomen down the region of the tied-off appendix. The incision was cIosed layer by layer, using pIain catgut continuous sutures for the peritoneum, continuous chromic catgut sutures for the aponeurosis, and interrupted fine siIk sutures for the skin. Recovery was uneventfu1, and the chiId was discharged in good condition Jufy 16, 1932. Final Operative Diagnosis: Acute gangrenous appendicitis, with abscess. Microscopic Diagnosis: Acute exudative appendicitis with peritonitis. Microscopic examination of the removed appendix reveaIed an acute exudative inffammatory Iesion, with de& nite peritonitis. CASE II. Case No. 7193. Mrs. B. S., aged thirty, was admitted to New York PoIycIinic Hospital December 27, 1930, with a history of three abdomina1 operations performed elsewhere within the preceding five years. At her first operation, which was said to have been for appendicitis, the appendix, to the best of the patient’s beIief, had been removed. Pains persisted, however, and two additiona operations were necessary at different times, but stiI1 no reIief was obtained. For the last one and one-half years the patient had suffered at irregular intervars with pain over the suprapubic region and right Iower quadrant. It was sometimes sharp and severe. The pain started over the hepatic region and radiated to the Ieft and right sides. It had graduaIIy been growing. worse and was at times attended by chills and fever, nausea and vomiting. Provisional Diagnosis: Incomplete intestina1 obstruction due to postoperative adhesions. Operation: At operation, on December 29, 1932, the abdomen showed cicatrices representing the incisions of the three former operations, a11of which were in the neighborhood of the right iliac fossa. Our incision was made through the right rectus muscle. When the abdomen was opened, the intestines were seen to be bound together by very dense adhesions, the omentum being adherent in the abdomen to the bowe1 and in the peIvis to the bIadder and fundus uteri. Numerous coiIs of smaIi intestine were densely adherent within the peIvis. Many of these adhesions had to be separated before the cecum couId be found and brought up into the incision. A mass about 3 inches long corresponding to the appendix was

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then found, which was detached from its adhesions with some diflicuIty. This was removed by the carboIic knife method after a chromic catgut Iigature had been thrown around its root and tied. The stump was then treated with aIcoho1 gauze wipe. The part of the omentum which was adherent in the peIvis was detached and a portion about 3 inches in length cut away, after being Iigated with pIain catgut. Numerous coils of gut were freed from their adhesions, some being so firm that it was necessary to divide them with a knife. The tubes were seen to be somewhat distended and in a state of Iow chronic inflammation. The incision was cIosed layer by Iayer with the usua1 technique. Recovery was uneventfu1, and the patient was discharged cured on January 12, 1931. Microscopically, the appendix showed fibrosis, edema and a weII-marked chronic inffammatory response upon which was superimposed a subacute Iesion. It appeared to show an incompIete rupture which was now fibrosed and partiaIIy heaIed. Final Diagnosis: Subacute and chronic appendicitis. IncompIete intestina1 obstruction due to postoperative adhesions. CASE III. Case No. 3871. Mrs. B. K., aged twenty-three, admitted to New York PoIycIinic HospitaI December I, 1932, with a provisiona diagnosis of peritonea1 abscess. The patient stated she had been operated on for appendicitis two years previously, after which drainage through the wound continued for about five months. She was then reoperated upon and made a good recovery, remaining in good health unti1 the present iIIness began, about three months before admission, with pain over the area of the appendectomy scar. About three weeks before admission there was discharge of about a cupful of pus from this scar, which had since healed over again. PhysicaI examination revealed a tumor mass the size of a grapefruit in the appendicial area. With a provisiona diagnosis of peritonea1 abscess, operation was performed on December 2, 1932, consisting of re-expIoration and drainage of the retroceca1 region. Upon inspection the Iower part of the abdomen showed a scar of an incision of previous operation. A mass was feIt in the right iIiac region, nearIy immovable, resistant and firm, about 4 by 8 inches in diameter.

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An incision was made through the right rectus muscIe. Upon entering the abdomen, it was observed that the mass aheady referred to was densely adherent to the peritonea1 surface and couId be exposed onIy when the parts were separated, partIy by bIunt detachment and partIy by cutting. It was found to consist of a thickened cecum, particuIarIy the mesenteric portion of the Iatter and of parts underIying which were probabIy enIarged diseased Iymph nodes. A search was made for the appendix or a portion of the appendix, or for a possibIe abscess from the old appendicia1 operation; but nothing of this sort was found. The cecum was mobiIized, after which search was made for a possibIe IocaI abscess coIIection in the posterior aspect of the cecum; but neither was this found. A cigarette drain was introduced into the region of the iIeoceca1 junction and the abdomen cIosed in Iayers, using pIain catgut continuous sutures for the peritoneum, continuous chromic catgut for the aponeurosis, and interrupted sutures of B & B and fine siIk for the skin. The impression from the investigation made in the course of the operation wouId indicate that we were deaIing with a chronic inffammatory process, possibIy invoIving connective or gIanduIar tissue in the retroceca1 region and Iymph nodes aIong the course of the iIiac vesseIs. AIthough the entire aspect of the mass encountered gave very striking indications of a maIignant mass, nevertheIess, in view of the patient’s youth, the diagnosis incIined to be that mentioned above. Recovery was uneventfu1, and the patient was discharged improved on December 19, 1932.

On July 19, 1933, seven months Iater, the patient (now No. 3871) returned to the hospita1 for correction of a feca1 fistuIa which had persisted ever since her Iast operation and from which drainage was very profuse. With a provisiona diagnosis of feca1 iistuIa and tubercuIous coIitis, the patient was prepared for operation. Operation: Resection of cecum and ascending colon. Operation was performed JuIy 20, 1933.

Upon inspection the skin in the right iIiac region presented a scar from previous operations and an opening through which pus and feca1 materia1 escaped. An incision was made from above the region of the umbiIicus downward toward the symphysis pub&. The ab-

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domen was entered and a mass about 6 inches by 4 inches in diameter was found presenting in the iIiac fossa. It was firmIy adherent to the wall of the peIvis and adjacent parts and apparentIy invoIved the waI1 of the cecum, ascending coIon and adjacent glands. This mass was freed a11 around and brought up into the incision, where it was recognized as the head of the cecum and the ascending coIon. The entire mass was resected, section being made across the iIeum near the iIeoceca1 junction and across the colon at the hepatic flexure. A IateraI anastomosis was then made between the iIeum and transverse coIon, using the suture method without clamps. The incision was cIosed Iayer by Iayer in the usua1 way, except that in the Iower end of the incision a cigarette drain was placed. The patient made an uneventfu1 recovery and was discharged cured on August 14, 1933. Histological Report: The specimen consisted of a mass of cecum measuring 20 cm. in Iength. It was matted together, and if stretched wouId have measured 3.5 cm. in Iength. SeparateIy was found a smaI1 portion of skin and sinus tract. About 14 cm. of the specimen was made up of ileum. At the iIeoceca1 junction there was a hard, indurated, anguIar, buIky and tumor-Iike mass invoIving the waI1. About 6 cm. beyond the junction was found a soft, somewhat uIcerated area. In one portion of the tissue there was a smaI1 diverticuIum and, at another point, what appeared to be the stump of the appendix. A point of uIceration was found just above the soft, ulcerated area. The Iymph gIands in the fatty tissue were greatly enIarged. AJicroscopical examination showed a chronic inflammatory Iesion with considerabIe fibrosis. A large number of eosinophiIs and mononucIear ceIIs were found. In some areas an occasiona muItinucIeated giant ceI1 was seen. There was nothing typicaIIy diagnostic of tuberculosis about the slide, aIthough tubercuIosis in the background was a possibility. However, we are inclined to beIieve that it was essentiaIIy an inff ammatory condition arising around the diverticuIum and the stump of the appendix. There was no evidence of maIignancy. The Iymph glands were Iarge and showed a weIImarked simpIe Iymphadenitis. Microscopical Diagnosis: Chronic diverticuIitis of the cecum; chronic ceIIuIitis of the cecum; abdomina1 fistuIa foIIowing coIostomy.

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coIitis and peri-

coIitis; feca1 fistuIa. DISCUSSION

These 3 cases cIearIy iIIustrate the subsequent history of cases in which incompIete operation has been done in appendicitis accompanied by IocaIized suppurative peritonitis. In the first case, a young chiId had suffered three months previous to observation with a ruptured appendix, which was drained but not removed. The acute pains of a secondary appendicitis inevitabIy appeared and at operation the abdomina1 cavity was found fuI1 of pus and masses of adhesions, among which the gangrenous appendix was discovered and removed. In the second case the patient had been operated on for appendicitis five years before observation, but the appendix was not removed. Since pain persisted, with attacks of chiIIs and fever, nausea and vomiting from time to time, two other operations had been done, the nature of which was not stated, but undoubtedIy drainage was attempted. As there was stiI1 no reIief of symptoms, the patient returned once more for operation and thus came into our hands. The dense adhesions between omentum and coiIs of intestine were characteristic. The appendix, which was edema and removed, showed fibrosis, inffammation, with indications of an oId rupture which was now fibrosed and partiaIIy heaIed. This was a case of subacute and chronic appendicitis, with incompIete intestina1 obstruction due to postoperative adhesions. The third case was that of a young woman upon whom two previous operations had been performed for appendicitis. Pain continued, however, and there was constant drainage through the wound. At Iength a cupfu1 of pus was rather suddenIy discharged and the patient was admitted shortIy afterward for re-expIoration and drainage of the retroceca1 region. There was a tumor mass as Iarge as a grapefruit in the appendicia1 area.- It was

JANUARY,1933

found to consist of the thickened cecum and of parts underIying which were probabIy diseased Iymph nodes. A search for the appendix faiIed to revea1 it, nor was any abscess in the posterior aspect of the cecum found. AIthough the mass gave suspicious indications of being maIignant, in view of the patient’s youth a diagnosis of tumor of the head of the cecum was made. After a period of drainage the patient was discharged improved. She returned seven months Iater with a feca1 fistuIa and chronic coIitis, possibIy tubercuIous. The tumor mass, denseIy adherent to the waI1 of the peIvis and invoIving the cecum, ascending coIon and adjacent mesenteric gIands, was now resected and a IateraI anastomosis made between the iIeum and transverse coIon. It is thus seen that a Iarge amount of repair work and revision remained to be done in a11 these cases as a resuIt of incompIete primary operation, which had Ieft the patients suffering with adhesions and suppurative conditions that necessitated later correction. In the end the appendix had to be removed, after aI1. The findings are not unIike those that we often encounter in operations for chronic appendicitis when this has been preceded by acute attacks which did not come to operation. If the attacks have been severe, an intense peritonea1 reaction has been invoked, with formation of extensive suppurative foci. The omentum, in its effort to waI1 off infection, has sent runners into deep regions, where it adheres intimateIy, onIy to become itseIf the seat of a chronic inffammation such as sometimes foIIows inff ammation of other abdomina1 viscera. AbnormaI connections are formed between the intestines and parieta1 geritoneum, binding together with thin, vascuIarized membranes the externa1 surfaces of the cecum, iIeum and coIon. PeristaItic movements are accordingIy hindered, especiaIIy in the cecum and ascending coIon, which are converted into a semirigid cylinder. Fibrous cords and trabecuIations

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bind these various structures to one another and may even anchor them to the parieta1 peritoneum, the bottom of the Sac fossa, Iumbar fossa, etc. The traction resuhing when the intestine makes attempts at peristaIsis is readiIy understood, and it must inevitabIy Iead to a painfu1 symptomatoIogy and functional disturbances which at Iength necessitate further surgica1 intervention. WhiIe there is practica1 unanimity in the view that the appendix shouId be removed in earIy cases where the inffammation is stiI1 confined to the appendix itseIf, we begin to lind divergence of opinion with regard to the proper procedure when it comes to the beginning of a circumscribed peritonitis. With some authors the time eIement is everything and an appendix that has been giving symptoms for Iess than fortyeight hours is regarded as an earIy case that can bear watchfu1 waiting before deciding upon action. Yet BIack5 found an appendix ruptured within four hours of its first symptoms, and FinIey2 reports 2 that had ruptured in Iess than six hours, 42 at the end of twenty-four hours, and 64 by the end of forty-eight hours, with rg deaths among this number. On the other hand, Quain and WaIdschmidt,6 who reported on IOOO consecutive cases, have observed many cases in which the appendix was in a state of acute inffammation for severa days before it became surrounded by infectious exudate. In many cases of this kind heaIing occurs promptIy after appendectomy and without marked inffammatory reaction, so that they consider it unfair to incIude such cases among those of Iate appendicitis or peritonitis, even if three or four days have eIapsed since the first symptoms appeared. They beIieve that the surgeon shouId judge rather by what he sees and feeIs, with the pathoIogica1 process before his eye, than by what he remembers of the time of onset. The experience of Quain and WaIdSchmidt with reference to drainage without

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removing the appendix is very instructive. They did primary appendectomy in 262 of 289 appendicia1 abscesses, Ieaving 27 with drainage and with the appendix Ieft in. In some of these cases, drainage per vaginam, in others the presence of compIicating diseases, made appendectomy seem contraindicated. But in most, the appendix was Ieft behind onIy because it couId not be Iocated without too much manipuIation and Ioss of time. The postoperative compIications were proportionaIIy greater here than in the rest of the group. A much Ionger period of hospitaIization was necessitated by the proIonged suppurations which usuaIly foIIowed non-remova of the appendix. Most of the secondary abscesses and additiona operations for their reIief and nearIy one-haIf of the postoperative enterostomies for obstruction of the boweIs were among these same 27. The appendix had not been removed in 3 of the 7 cases of abscess in which death occurred. “We fee1 convinced,” say these authors, “from a comparison with earIier experiences in progressive peritonitis that a ruptured appendix remaining in the abdomen after a simpIe drainage operation acts as a potent feeder for further extension of the infection and compIications. When the cause is removed, the patient has a better chance to overcome the damage aIready wrought on the peritoneum.” A different view is expressed by Braddon,7 of AustraIia. Most of us, he says, have witnessed the tragedy of the conversion of a IocaIized abscess into a generaIized peritonitis. He regards surgica1 intervention as particuIarIy dangerous between the third and fifth days, since at this period the natura1 immunity is exhausted and acquired immunity is not yet fuIIy estabIished. If adhesions are broken down and fresh pIanes are opened up to infection, during this negative phase of immunity, he fears, the patient may be unabIe to resist the additiona strain upon the protective mechanism. In these cases he wouId at this period use the Ochsner

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expect ant treatment, draining an abscess if a tumor is present, but otherwise deferring operation unti1 two to three months Iater. If, however, genera1 peritonitis shouId deveIop despite the Ochsner treatment, he wouId do a Iate appendectomy; for under these conditions he, too, has found that mere drainage of the peritonea1 cavity without remova of the constant stream of infection is very disappointing as a ruIe. Chittyg advises just as strongIy against operation in cases seen Iate which aIready show signs of IocaIized tumor formation. “In these,” he says, “hold your hand unti1 the attack has entireIy cIeared up, or unti1 an easiIy accessibIe abscess has formed. . . . In draining an abscess, do not try to remove the appendix if by so doing you run any risk of breaking down protective adhesions.” This author thinks that 2 cases which terminated fataIIy couId have been saved, had he not removed the appendix when it was associated with abscess formation and, in so doing, broken down protective adhesions and set up a genera1 peritonitis. MiIIerg takes a simiIar view. After the appendix has perforated he wouId never operate where there is evidence of streptncoccic or pneumococcic appendicitis, or in diffuse peritonitis of so high a degree as to worry the surgeon. But in abscess he beIieves the surgeon’s incision is aIways indicated and drainage shouId be done. WiIkinson,lO on the other hand, who reported a series of g8 cases of suppurative peritonitis, of which g3 were IocaIized and 15 had formed abscesses, promptIy removed the appendix in a11 but 3 cases, after carefuIIy waIIing off the intestines and protecting the abdomina1 waI1 by saIine sheets. He did this on the ground that such remova markedIy shortens the period of convaIescence and is therefore the proper procedure unIess the patient’s condition is such that removal might be dangerous. FinIey,2 in 1933, reviewing 3913 operative cases, of which I 129 were acute

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unruptured with 16 deaths and 438 were acute ruptured with 20 deaths, writes: “Our contention is that ordinariIy the time to operate is as soon as the appendix can be reasonabIy suspected; the onIy safe appendix is one in a bottIe.” Deaverl’ is emphatic on this subject in a11 his writings. In the presence of a circumscribed peritonitis, he regards remova1 of the appendix as the correct thing to do. If the appendix is not at once in sight, he immediateIy Iifts up the overIying abdomina1 waIIs and thoroughIy packs off the surrounding peritonea1 cavity with moist gauze pads. If pus is found, it is mopped up during the dissection in freeing the appendix. He aIways explores the externa1 paracolic groove, and if he finds pus there, continues to expIore higher up and often finds a coIIection between the diaphragm and Iiver as we11 as beneath the Iiver. He drains this thoroughIy. He attributes his success to the Iocation of the coIIection or coIIections of pus and to the proper disposition of guaze pads, “to which,” he remarks, “Murphy once said ‘Amen.“’ He feeIs that not to remove the appendix at once is to endanger the patient’s Iife. FuIminating, expIosive appendicitis means a Iarge perforation and operation shouId be done at once if the patient is seen earIy. Catterina12 says it shouId be borne in mind that, when the intervention is done within three days from the beginning of the attack, the adhesions that may have formed are not so tenacious as to make it wise to Ieave the appendix and Iimit the operation to drainage. In these cases great patience is required to work with a deIicate technique: One shouId never give up freeing the adhesions IittIe by IittIe unti1 fuIIy convinced of the impossibiIity of extirpating the appendix. He himseIf has aIways feared possibIe compIications that made him insist upon removing it, and he has been we11 satisfied with resuIts. He beIieves, however, that the appendix may be Ieft aIone temporariIy when one meets a weII-circumscribed peritonitis, and

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that the attempt to break up adhesions may incur the risk of generaIizing an infection that has aheady been IocaIized by nature herseIf. He keeps these patients in bed for two months with an icebag, and then reoperates for compIete appendectomy. Among those advocating immediate appendectomy with waIIing off of the infected region from the rest of the peritonea1 cavity by suitabIe pIacing of moist packs are Stowers, l3 Devine,l* Sponheimer, l5 Tasche and Spano,l” Stoney,l’ WiIkiel* and many others. WiIkie approaches the argument from another angIe. He beIieves that two distinct types of appendicuIar disease exist, due to two fundamentaIIy different pathoIogicaI processes: one, an acute infection of the appendix, with high temperature at the start; the other, an acute obstruction of the Iumen of the organ, with absence of fever during days when diagnosis is aIIimportant. He maintains that go per cent of the deaths are in the cases of primary obstruction of the appendix with resuIting tension, gangrene and perforation. Hence he stresses the importance of visuaIizing this disease as one of the fata types of acute intestina1 obstruction, with the afebriIe onset characteristic of such diseases, demanding immediate operation before the tense, obstructed organ bursts. ObviousIy, if this be true, attempts to drain the region around such an appendix without first removing the suffering organ itseIf wouId accompIish nothing and wouId leave the source of the iIIness untouched. SOME

POINTS

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TECHNIQUE

In doing primary appendectomy in cases of circumscribed suppurative peritonitis, we have in mind the avoidance of preciseIy those unfortunate conditions which, as we have seen, resuIt when the appendix is Ieft in through fear of spreading infection. In order to accompIish this end, a wide exposure is necessary to permit waIIing off of the infection from other

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parts of the peritonea1 cavity. As a ruIe, we prefer the BattIe incision for this reason, since it gives pIenty of room both for expIoration and for pIacing of packs. After the incision has been made and the abdomina1 waI1 lifted away from the viscera, any adhesions that may be encountered in the immediate fieId are severed to create an adequate space for expIoration of the appendicia1 region. Adequate operative exposure, which makes it possibIe to dissect under sight, wiI1 aIso greatIy faciIitate discovery of the appendix in cases where this organ is bound down by adhesions, or where, as so frequentIy occurs in appendicitis, the appendix occupies an anomaIous position, appendices of this type seeming to be particuIarIy IiabIe to faI1 prey to pathoIogica1 conditions. This has been pointed out by BIack,5 who in 14 fata cases of appendicitis found the appendix 7 times in peIvic, 3 times in retroceca1, 2 times in spIenic and 2 times in IateraI ceca1 position. Without adequate exposure it wiI1 often be impossibIe to discover the appendix, and for this reason surgeons not infrequentIy give up the attempt in cases of severe abscess conditions, when an incision better favoring wide access to the fieId of operation wouId have made it possibIe to remove adhesions that were present and to discover and dissect out the appendix, no ‘matter how anomaIous the position or how dense the adhesions, without soiIing of the intestine or dissemination of infection to other parts of the peritonea1 cavity. Wide exposure also faciIitates the contro1 of bIeeding. It is our conviction that the more conceaIed and diffIcuIt of discovery an appendix is in these suppurative cases, the more insistent the surgeon shouId be on unearthing it and cIeaning out the bed that has served as a breeding pIace for infection. Not infrequentIy these conceaIed appendices give rise to muItipIe conceaIed pus pockets, often intercommunicating. If these are not found and removed, the way is Ieft paved for further troubie, for

120

American Journal of Surgery

McGrath

& Eiss-Appendicitis

it is idIe to expect nature unaided to cIean these up. ImmediateIy after making the incision, intestina1 Ioops, stomach or any other structures that may Iie at hand are cIeared away from the fieId of operation and incarcerated under the abdomina1 waI1 by means of hot moist gauze packs covered with gutta percha. In this way Ioops of intestine are prevented from extruding through the abdomina1 incision, where they are subject to bruising and must inevitabIy tend to spread the infection, besides suffering the disadvantage of Ioss of heat. These hot gauze packs serve the doubIe purpose of protecting the abdomina1 waI1 and viscera from infection and aIso of keeping the intestines warm. They are inserted with great care and in such a way that a11 contamination of the exposed peritonea1 surfaces during operation is absoIuteIy prevented. It is unfaiIingIy necessary to see that the disposition of these pads is properIy made before the puruIent coIIection is attacked. When this is done correctIy, the remainder of the peritonea1 cavity is compIeteIy isoIated and secure from contamination even, in the presence of severe gangrene, perforation and other compIications. If in spite of a carefu1 technique, compIications arise inevitabIy, such as the rupturing of a friabIe inffamed appendix by the surgeon himseIf in the act of deIivering it, the free peritonea1 cavity is protected with absoIute certainty. Pus or free fluid that may be encountered is either mopped up or removed by aspiration, using the abdomina1 suction tip. This exudate, aIthough it is the expression of a heaIing process on nature’s part, becomes toxic after a few hours and tends to deIay or compIicate recovery, s&e it offers a ready cuIture medium for pathogenic microorganisms. Drainage, when instituted, is accompIished by strips of gutta percha or rubber tissue and never by rubber tubing if this can be avoided, since the Iatter is IiabIe to produce feca1 fistuIae that bring the

JANUARY.,933

patient back sooner or Iater for their correction. Gauze is unsatisfactory, because it does not drain; on the contrary, it serves to bIock drainage and thus encourages muItipIication of infection. It is important, in cIosing the wound, not to do this so tightIy that pus cannot readiIy escape. The amount of drainage to be provided wiI1 of course depend on the extent of the peritonea1 infection, but there shouId be no attempt to spare drainage in cases where it is caIIed for. In some cases we have used as many as IO or I 2 Iong and soft gutta percha cigarettes, reducing this number as the exudate becomes Iess, which shouId be the case in three or four days. CONCLUSIONS I. In acute appendicitis it is not enough mereIy to save Iife. The aim shouId be to restore the patient to compIete heaIth and efficiency with as IittIe deIay as possibIe. 2. Many surgeons in doing appendectomy, when they find pus, simpIy drain and Ieave the appendix aIone, because they are afraid of spreading a IocaIized peritonitis. 3. This poIicy resuIts a11 too frequentIy in a period of invaIidism foIIowing incompIete operation and in the end forces the patient to return for secondary appendectomy or other operations. 4. By carefuIIy waIIing off the infected area with hot, moist gauze packs, it is possibIe, even under the most unfavorabIe suppurative conditions, to dissect out the appendix and free adhesions without spreading infection. 5. Three iIIustrative cases show the evi1 effects of a conservative poIicy in acute suppurative appendicitis. REFERENCES I. WILLIS, A. M. The mortaIity

in important surgica1 diseases, especiaIIy appendicitis. Surg. Gynec. Obst., 42: 318, 1926. 2. FINLEY, J. M. T. Appendicitis. Some observations based upon a review of 3913 operative cases. Surg. Gynec. Obst., 56: 360, 1933. [For Remainder of References see p. 150.1

American

150

Journal of Surgery

Taylor-Extirpation

opposed to the radix or root proper). Healing was greatly delayed in these cases. A smaI1 area of gangrene adjacent to the naiI bed deveIoped in one patient who was undergoing simultaneous treatment for duodena1 ulcer. He was the only bed patient of the series. These cases, together with the serious secondary pyogenic infection, comprised the tota of comphcations. IndividuaIs with obstinate dermatophytosis who underwent the operation have been easily cured of the skin disease folIowing remova of the offending nails. SUMMARY

AND

CONCLUSIONS

TopicaI treatment of chronic fungus infection of the entire toe nail seIdom effects permanent cure. X-ray radiation is prohibitiveIy dangerous. 2. RemovaI of the nai1 with excision of soft parts overIying its base and sides permits adequate exposure of the growing nai1 to fungicida1 appIications. 3. Permanent ablation of chronicaIIy infected toe naiIs is clinically feasible and assures cure with minimum after-care. I.

REFERENCES

OF

DRS.

4. The most active foci of nai1 regeneration are situated at the comers and proxima1 thirds of the sides of the nai1 bed; at the base of the not, as supposed, nail. 3. A technique is described which assures permanent nai1 ablation without exposure of bone or shortening of the toe. IndividuaIs deprived of toe naiIs in this manner suffer no lasting inconvenience. REFERENCES I. WISE, F. The treatment of ring worm infection of the hands and feet. N. York J. IV. (Dec. I) 1929. 2. SHAMBERG,J. F. et al. Chemotherapy of ringworm infections. Arch. Dermat. ti .$pb., 29: 937-I 150 (Dec.) Ig3I. 3. KINGERY, L. B., and THIENES, C. H. Vycotic paronychia and dermatitis; a hitherto undescribed condition apparentIy peculiar to fruit canners. Arch. Dermat. TV Sypb., I I : 186 (Feb.) 1925. 4. STEVENSON, J. Ringworm of the hands and feet. J. Oklaboma M. A., 22: I 13, Ig2g. 5. TAYLOR, K. P. A. Treatment of ringworm infections of the feet with the ethyl chloride spray. Soutbern M. J., 23: I 128 (Dec.) Ig3o. 6. LAPIDUS, P. W. Complete and permanent removal of toe nail in onychogryposis and subungual osteoma. AM. J. SURG., n.s. rg: 93 (Jan.) 1933.

MCGRATH

3. LOWE, H. A. Causes of high mortality in appendicitis. J. Missouri M. A.; 28: 525, 1931. _ _ A. MONTANARI.E. Interventi radicali dooo ooerazioni incomplete per appendicite acuta e p’eritonite 12. circoscritta. Arch. ed affi d. Sot. ital. d. cbir., 36: 870, rgzp-rg3o. 5. BLACK, J. IM. A survey of 340 cases of acute appendicitis. Brit. M. J., 2: 1136, 1932. 13. 6. QUAIN, E. P. and WALDSCHMIDT,R. H. Acute appendicitis with a report of 1000 consecutive cases. Arch. Surg., 16: 868, 1928. 14. 7. BRADDON, P. D. The Ochsner-Sherren deIayed treatment of negkcted appendicitis. Med. J. Australia, 18: 660, rg3I. Is’ 8. CHITIT, H. A review of 7oo cases of acute appendicitis. Bristol Med.-Cbir. J., &: 167, 1931: _ 16. a. MILLER. E. L. When not to oDerate on a case of acute.appendicitis. J. Missoh M. A., 28: 528, 1931. 17. 10. WILKINSON, R. J. Suppurative appendicitis. West Virginia M. J., 27: 346, 1931. 18. I I. DEAVER, J. B. Append&a1 peritonitis. Surg. Gynec. Obst., 47: 4oor. 1928. l Continued from 1

JANUARY.,933

of Nails

AKD

EISS*

Appendicitis. J. A. M. A., go: 1679, 1928. When and when not to open thkabdomen in acute surgicaI conditions. Ann. Surg., 8g: 340, rgzg. CA~~RINA, A. Considerazioni &niche su IOO casi di appendicite acuta trattati chirurgicamente. Arch. ed atti d. Sot. ital. d. cbir., 36: 943, Ig2g1930. STOWERS, J. E. Treatment of acute appendicitis in its two phases: before and after operation. J. Missouri-M. A., 28: 531. Ig3I. DEVINE, H. B. Abdominal technique-a system of operative exposure. Surg. Gynec. Obst., 50: 455, 1930. SPONHEIMER, K. Ueber die Behandlung der akuten Appendicitis. Zentralbl. f. Cbir., 60: 321, 1933. TASCHE, L. W., and SPANO, J. P. Analysis of 700 consecutive appendectomies. Ann. Surg., 93:

899, 1931. STONEY, R. A. Results of appendix Irisb J. M. SC.. Nov., 1932. p. 645.

operations.

WILKIE, D. P. D. Some principles in abdominaI surgery. Surg. Gynec. Obst., 50: 129, Ig3o. p. 120.