COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES SrANDARD HX64067017 R D542 B38 is appendicitis a su RECAP Carl Beck Is ADpendicitis a Surgical Disease? 1\'M^ BJ^ Columbia (HntDersd'tp intljeCttpofllfttigork COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/isappendicitissuOObeck IS APPENDICITIS A SURGICAL DISEASE? CARL BECK, M.D., HEW YORK. BEPBINTED FROM THB "Neto York iWetJfcal Journal for November, IS, 19, and 26, and December 10, 1898. Reprinted from the New Tork Medical Journal for November 12^ 19^ and ^6, and Becernber 10^ 1898. IS APPENDICITIS A SUKGICAL DISEASE? By carl beck, M. D., NEW TORK. Appendicitis is an inflammation of the vermiform process due to infection. Is such infection due to the invasion of a specific bacterium, or to the cooperation of two or more different species? The question is not yet settled; but the majority of observations point toward the ubiquitous Bacterium coli commune as playing the main part in the infection. Other species are found in the colon : the Streptococcus lanceolatus, the Bacillus pyogenes^ the different varieties of proteus, the Bacillus suhtilis, and sometimes staphylococci. Streptococci are found more frequently ;, the liquefying as well as the non-liquefying type. Eegarding the repute of the streptococcus, it is no more than natural that there is an inclination to hold it responsible to a great extent for originating appendicitis, especially in its highly virulent forms. Welch maintains that it is the combined influence of the colon bacterium and streptococcus which causes appendicitis, and that the failure to discover strepto- cocci on the artificial soil does not necessarily prove COPTRIGUT, 1898. BY D.^'APPLETON AND COMPANT. 2 IS APPENDICITIS A SURGICAL DISEASE? their absence. The colonies of the Bacterium coli com- mune grow so rapidly, and are so overshadowed, that they are overlooked. So it might be that from the stand- point of the companionship of two different types of bacteria the higher toxic potency of the various types of appendicitis could be explained. Whether each of these bacterial species alone will originate appendicitis, or whether two or more associ- ated species together are required, has as yet not been practically demonstrated. Theoretically, there seems to be no reason why each pathogenic species alone could not produce the infection. It is a well-known fact that the virulence of the Bacterium coli coinmune sometimes may become enormous. According to Lesage and Ma- caigne {Archives de med. experiment, et d'anatom. pathol., 1892), it produces but insignificant effects if grown on a healthy surface, but causes the most intense reaction when isolated from tissues which have under- gone pathological changes. Thus its virulence is the higher as the disease is graver in which this bacterium is found. The fact that cultures taken from a case of cholera showed a high virulence, while those taken from a pus focus were weak, is in entire accord with this theory. It will be reserved for the cooperation of sur- geons possessing bacteriological knowledge to appreciate these different theories so far that practical results can be deduced from them. One of the greatest difficulties in estimating the toxic dignity of the Bacterium coli commune is caused by its not representing a distinct uniform species, but a whole series of different subspecies, which, while alike in many respects, still show a few small but neverthe- less well-marked diversities. The great difficulties of IS APPENDICITIb A SURGICAL DISEASE? 3 differentiation may best be illustrated by the fact that Park goes even as far as to maintain that the Bacterium coli commune should probably be identical with the Bacillus neapolitanus Esclierich, the Bacillus foetidus Passet, the Bacillus aerogenes, and a variety of other forms. It is well known that the much-debated Bacterium coli commune is the most common inhabitant of the in- testines of man, as well as of many animals, such as the dog, cat, goat, hog, cow, mouse, rabbit, etc. Thorough examination reveals the presence of this ubiquitous bac- terium in the oral cavity of almost every healthy person. As long as the mucous membrane of the intestine i? normal, it causes no disturbance whatsoever. But as soon as there is the slightest erosion of the epithelium, it will readily be absorbed. This will happen so much the easier when there are other disturbances in the intes- tina.l tract. According to Gilbert, Eoger, and others, it forms very virulent tissue-change products, which are probably rendered innocuous by the liver, or more so by the bile. There is no better proof for the fact that disturbances of circulation offer a most provoking moment for infec- tion than the experience that in hernial incarceration it is found, having advanced as far a*s to the serosa. That abrasions of the mucous membrane are the avenue for the invasion is evidenced also by the frequent pres- ence of the Bacterium coli commune in dysentery, ty- phoid fever, and cholera. And there is hardly any other organ of the human body where the chances of a circu- latory disturbance and of the abrasion of the mucous membrane are offered with such frequency as in the vermiform process. We need only to consider its situa- 4 IS APPENDICITIS A SURGICAL DISEASE? tion above the ileo-psoas, a muscle so extensively used, the length of its channel, which is in no proportion to its small calibre; furthermore, the shortness of its mesen- teriolum, and last, but not least, its low power of ex- pulsion. Eemembering the scantiness of its muscular tissue — there is but a small circular layer — this lack of expelling power can be well appreciated (Fig. 1). j^<^?^.^ijK^^Vv.:i-:;":- ->"^V>f:-- Gland. _^Si^35'^v^»r^§r^«5-^^^5^'^ Submucosa. ^"^ ^% <^<^ Circular, 1 ,, -^ . - _^^Loiisifudiiial. j '^''''^■ ~ zi:_-rg n^ Serosa. Fig. 1.— Section through normal appendicular wall. A certain amount of circulation, however, in the vermiform process must be possible. I have made it a rule for several years (see Journal of the American Medical Association, December 28, 1895) to examine the vermiform process in each case of abdominal section. I have repeatedly found masses of moderate hardness, probably faecal concretions, in individuals who had never up to that time and have not since then shown any symptoms of disease of this organ. Slight pressure suf- ficed to void such contents into the caecum. Appreciating the fact that in the majority of cases the vermiform appendix reaches as far as the true pelvis, it can easily be explained how kinks and twists are caused, which are apt to prevent mechanically the evacua- tion of the appendicular contents into the caecum. The limits of this work forbid my entering into the various occasional causes more particularly. I shall only re- I IS APPENDICITIS A SURGICAL DISEASE? 5 mark that, regarding my own experience in two hun- dred and seven cases of appendicitis, I feel justified in emphasizing the rarity of real foreign bodies. Only twice have I found real foreign bodies in the appendix — once the traditional grapeseed, and another time a few cumin seeds. Fsecal concretions are frequently found — I have seen them forty-two times — almost always in the gangrenous form. There is another Eetiological factor „ ^ , ° Fig. 2. — Faecal con- the pathological significance of which cretion from a has, so far as mv knowledge goes, as vet gangrenous ap- ' " 00;'. pendix. not been studied — namely, the right floating kidney pressing the appendix, if directed back- ward toward the ileum. In the case of two men, one being thirty-three and the other nineteen years of age, slight pain existed for years, the intensity of which increased gradually. In both cases it was located partially in the lumbar and hip-joint region, and partially in the right iliac fossa, so that lumbago as well as coprostasis was repeatedly diagnos- ticated. In the case of the nineteen-year-old patient even coxitis had been thought of, because the right leg appeared to be slightly shortened. In both cases a skia- gram had been taken, which illustrated the integrity of the bones. Having been able to palpate a slight resist- ance in the depth of the iliac fossa, I thought of chronic appendicitis, and opened the abdomen. In both cases a movable kidney was discovered, which reached down into the fossa, pressing the appendix against the ilium at each inspiration. After their removal, both appen- dices, which appeared normal on the outside, showed strictures and contained a small quantity of discolored 6 IS APPENDICITIS A SURGICAL DISEASE V and decomposed faeces. Nephropexy was performed at the same time and up to date, fifteen and ten months after the operation, no pain was noticed by either of the two patients. In the case of a lady, thirty years of age, on whom I operated in the second attack I found the appendix buried by the side of the caecum in such a manner that at first sight there seemed to be no appendix at all. It was only after some search that its structure could be identified, for it had almost become an integral part of the caecum. Close examination revealed a deep-seated kidney pressing the caecum down against the ilium. The appendix, which was directed backward, had been pressed against the ilium so that it had become flattened, and at the time of the first attack the serous surfaces of the appendix and csecum were fused together, the appen- dix being imbedded in a groovelike depression on the caecum. By careful dissection with a grooved director it was enucleated. At its tip there was a small perforation containing thick, yellow pus. It was removed, the stump was tied, and the wound was treated by the open method. The patient recovered. In this case there had been digestive disturbances for years, and at one time cholelithiasis had been suspected. Edebohls, to whom we are so very much indebted for the discovery of the means of palpating the appen- dix, mentions the frequent occurrence of appendicitis in connection with floating kidney in general, attribut- ing the pathological change of the appendix to the dislo- cation of the duodenum and pancreas and compression of the superior mesenteric vessels between the head of the pancreas and the bodies of the spinal vertebrse. But it seems to me that the deeply situated movable kidney IS APPENDICITIS A SUEGICAL DISEASE? 7 exerts its pathogenic influence directly upon the ap- pendix. Thus disturbances of circulation may be produced which, while in themselves of a slight nature, are still sufficient to cause swelling and obstruction, even after the original cause, the twist, the kink, or the compres- sion have again ceased to exist. The swelling of t]ie mucous membrane is usually at the spot where its circu- lar duplicatures are found, as, for instance, above Ger- lach's valve, which corresponds to the ostium of the appendix at the caecum. Naturally, the appendicular secretion is apt to be retained below there. The further consequences are its decomposition and irritation. The presence of faecal concretion may represent an additional getiological factor as a mechanical insult. As alluded to, the contractility of the appendix is slight under ordi- nary conditions. How much more its contractility will be impaired, if there be a swelling, and a swelling means the presence of oedema, can easily be imagined. And, moreover, how fruitful a field for the develop- ment of bacteria is this hollow organ, which resembles a caecum in miniature. Its comparison with the tonsil in view of its glandular richness, unequaled by any other portion of the intestinal tract, is quite obvious. To appreciate the analogy, there is no nee|i to go as far as Golouboff {Berliner Jclinische Wochenschrift, 1897, No. 5) did, who regards appendicitis as of epidemic origin, just like a tonsillar angina. But by consider- ing that the appendix is in itself a large blind alley, while the tonsil is a conglomeration of many small blind alleys, by further realizing that both organs touch the two body cavities abounding more with bacteria than any other, the comparison can not be helped. There are a S IS APPENDICITIS A SURGKJAL DISEASE y few other factors j^ointing to the similarity — namely, the well-pronovmced predilection for an early age, espe- cially in the male, and the early manifestation of the inefficiency of their expulsive power against bacteria invasion, according to their anatomical structures. For a better understanding, the anatomical relations, Organizing fibrin. Mucous membrane with glandular fragments. Submucosa. Circular. Longitudinal. Serosa. Fibres of nius- cularis. Fig. 3. — Appendix wall in simple appendicitis. as shown in Fig. 1, should be recalled. There we have to deal with a mucous membrane containing little epi- thelium and a glandular and submucous layer, the lat- ter showing traces of a muscularis mucosa. Then fol- low the circular and longitudinal stratum, which are protected by the subserosa and serosa. IS APPENDICITIS A SURGICAL DISEASE? 9 There can be no doubt that once in a while the irritating contents force their escape into the cascum, and it is then that from a clinical standpoint the diag- nosis " colic of the appendix " will be made. But in far the greater majority of cases the invasion of bacteria into the submucosa means the breach being shot, and then there is no further halt to the progression of the infection. The muscularis rapidly being permeated, the sub- serosa and serosa are attacked soon. Accordingly the wall of the appendix becomes thickened. The contents of the channel become mucopurulent. This anatomical condition corresponds to what from a clinical standpoint is usually called " appendicitis simplex." Microscopically the vessels of mucosa and submucosa appear to be dilated and filled with red blood-corpuscles. In the tubular glands there is an accumulation of large cells and in the interstitial tissues there is an infiltration of embryonic cells. The infiltration with small cells proceeds to the muscular stratum and forces its fibres asunder, thereby causing complete paresis of the muscu- laris. Now the subserosa and serosa participate, too, showing considerable multiplication of their endothelial cells. There also fibrinous exudate may organize, lay- ing the foundation for partial obliteration. The mus- cular tissue, originally so scanty, may also participate in the proliferation and hypertrophy (Fig. 3). In this stage resolution takes place frequently — that is to say, the acute process subsides. But, according to my mind, restitution to perfect integrity seldom occurs. Sometimes the serosa may remain intact, but in most cases it will become adherent to the adjoining intes- tine, or to the omentum, or to the abdominal wall. 10 IS APPENDICITIS A SURGICAL DISEASE V The mucosa may, except at a few cicatricial points, the sequelce of erosions, appear to be normal. But these scars are the originators of strictures (Fig. 4), which cause stagnation, and stagnation again may cause dila- tation on other points. Thick mucous plugs, tightly crammed in, and organizing fibrinous exudates, ob- structing the lumen, are then found there (Fig. 3). The submucosa and mucosa become thickened and hyper- trophic, thus enlarging the dimensions of the whole appendix. Sometimes there results a progressive tendency to obliteration. This has been described most pictorially by N. Senn as appendicitis obliterans.* It goes without saying that all these conditions must necessarily provoke recurrence of an inflammatory pro- cess sooner or later. It is only when total shrinking of the appendix takes place, so that it is degraded to a simple, bandlike, functionless appendage, that such re- currence will fail to set in again. Thus the spontaneous cures are explained. In periappendicitis there is an adhesive peritonitis, combined with the formation of fibrino-plastic exuda- tion. There a resolution may take place in the same way as described in simple appendicitis — namely, the exudation may be absorbed and the acute inflammatory symptoms subside. The appendix of course remains in the same condition as if there had been an appendicitis simplex which had advanced as far as to .the serosa, plus the adhesion of its serous coat to the neighborhood, in which it sometimes appears like a mummy baked in lava. It does not need urging that under such circumstances recurrence of inflammation is provoked to a higher de- * Journal of the American Medical Association, March 24, 1894. IS APPENDICITIS A SURGICAL DISEASE' 11 gree than in simple appendicitis, mecliauifal causes now also being added. But very frequently resolution does not take place at all and the iutlannnatory process proceeds further. This can take place in different ways : The inflaniniation may encroach upon the tissues situated nearest to the serosa, and the exudation, origi- nally having been of a serous charac- ter, becomes purulent. It may safely be assumed, however, that the exuda- tion, which microscopically appears to be of a serous character, contains pyogenic bacteria a priori, the same as in serous pleuritic effusion, which " turns over into pyothorax " {'peri- appendicular abscess) . Or, the inflammation reaches the peritonaeum by way of the lymph ves- sels as a true lymphangeitis. I used to term this variety, in proportion to its propagation, either circumscribed or progressive phlegmonous appendicitis. Or, the secretion of the appendix becomes purulent {pyappendix) . Then in the vast majority of cases perforation takes place under suc- cessive distention of the walls and pressure necrosis. The perforated area may at first not be larger than the head of a pin and may enlarge gradually. Accordingly the pus may enter the peritoneal cavity slowly or rapidly. Fig. 4. — Long strictured appendix removed in chronic appendicitis. 12 IS APPENDICITIS A SURGICAL DISEASE? Naturally, the peritoneal area adjoining the nearest perforated spot is highly irritated by the preceding in- flammation, and therefore most susceptible to the fur- ther reception of the infections {appendicitis suppura- tiva perforativa) . But there may also be a suppurating nucleus, which, by forming adhesions and pushing them before itself, at last generates a partition-like, shut-off pus focus. Then the membranes, originally very thin, have a chance to distend gradually and gain strength by additional adhe- sive formation {encysted, isolated appendicular abscess). Finally, there may ensue ulceration of the mucous membrane, which deepens gradually in a funnel-like shape. The blood-vessels, possessing but scant anasto- mosis, are only too readily inclined to the formation of thrombi or emboli, so that there results an anaemic infarct; in other words, necrosis of the muscularis and serosa — i. e., a perforation hole. Great credit belongs to G. R. Fowler for having studied the significance of anastomosis formation in this most important relation. The experience of many authors, my own included, shows the great predilection for perforation at the prox- imal end of the appendix — that is, where there is the scantiest arterial supply. Kinks and adhesion with the adjacent tissues are factors favoring inflammation. Faecal concretions are to be regarded as the results rather than the causes of preceding pathological pro- cesses in the appendix. This type, which is to be called gangrenous appendi- citis, can be the direct consequence of the perforation form. But it can also encroach upon the appendix in its whole extent at once. Then the organ is found in the midst of decomposed pus, mutilated into a greenish- IS APPENDICITIS A SURGICAL DISEASE? 13 black band-shaped fragment, the connection of which with the csecum is entirely severed. In all these various types of a suppurative character a spontaneous favorable termination may occur, just the same as it occurs in infectious processes in other parts of the body. But it can not be disputed that such occurrences are extremely rare. The abscess may be evacuated through the abdominal wall, as well as through the intestine, the latter possibility being the most fre- quent. It may also happen that pus foci, especially if encysted, are absorbed after being thickened and hav- ing undergone fatty degeneration. This can be expect- ed so much easier if the bacteria contained by the pus died out, so that the pus lost its virulence. If the appendix be gangrenous, however, such possibilities can but very rarely be expected. It is evident that these various tjrpes can not always be kept asunder, but that one often passes into another. This consideration leads us to the most important point, that the difference of type mainly depends upon the stage in which the appendix is made accessible to ocu- lar inspection. This being possible only after the abdo- men is opened, it is self-understood that the different pathological conditions vary in proportion as they de- volve upon an advocate of early or lat^e surgical inter- ference. If the abdomen is opened at an early stage, the fol- lowing state is often found : The c»cal surface, as well as the adjacent intestines, show absolutely normal conditions. After the caput coli is lifted off', the appendix is found to be a rigid, firmly outstretched organ of the circumference of an index finger. It may properly be called an appendix in a state 14 IS APPENDICITIS A SURGICAL DISEASE? of erection. By thin fibrinous exudations it becomes adherent to its vicinity. Its general color is dark red, but in some places there are yellow-grayish foci, just like those seen in panaritium which is near perforation, the appendix wall having become so thin by ulceration that it is translucent, and the intra-appendicular pus is vis- ible. But there are no well-pronounced external signs of perforation (Fig. 5). Such an appendix, after being removed, shows its in- terior filled with a decomposed pulp of an offensive odor, which mainly consists of pus, blood coagula, and ne- crotic fragments from the mucous membrane. The muscularis is necrotic in various spots and the serosa is extensively inflamed. This condition represents a true empyema, or, as we may properly term it, pyappcndix, analogous to pyothorax, pyosalpinx, etc. (Fig. 6). If in such cases operative steps are omitted the lapse of an hour may cause a small-calibred perforation, fol- lowed by fulminant sepsis, or slow-forming gangrene may come on, with the same final result. On the other hand, the increase of the intra-appen- dicular pressure may have succeeded in extruding the appendicular contents into tlie caecum. But even under such apparently favorable circumstances it certainly often happens that the appendicular walls being so much infected, the near tissues have absorbed so much virus that further peritoneal infection can not be stopped even by eliminating the original noxiousness. We have to consider, in conclusion, what is called " chronic appendicitis,^' the frequent result of an appen- dicitis which took a " favorable course " after internal treatment. IS APPENDICITIS A SURGICAL DISEASED 15 This type, which is also frequently termed relapsing appendicitis, is characterized by a thickening of the whole sac, which is filled with a copious quantity of viscid mucus, sometimes mixed with pus. At some points there arc ampulla-like dilatations, due to the presence of turns, kinks, or strictures in the canal. Thus the expulsive power, so small in itself, on account of the scantiness of muscular elements, is so much more Fig. 5. — Pyappendix, remo\cd during an acute attack. Fig. 6.— Beginning perforation in pyap- pendix; extensive necrosis of mu- cosa and muscularis eleven hours after tlie beginning of the first clinical symptoms. diminished that decomposition of the contents and re- newed inflammatory manifestations must necessarily follow. It is customary to theoretically distinguish this type from recurrent appendicitis, defining recurrent appen- 1(J IS APPENDICITIS A SURGICAL DISEASE? dicitis to mean that after an acute attack and the disap- pearance of symptoms, a second attack takes place after a free interval, while in relaps- ing appendicitis there is no free interval, the patient never being completely normal and there being a tendency to numerous exacerbations. This differentiation, how- ever, is a rather arbitrary one, Fig. 7— Fibrous degeneration of and wllilc it SCemS to bc justi- appendix. Tubercular ulcer. g^^ clinicallv, it CaU UOt be (Caseous focus on the tip.) upheld from the standpoint of pathology ; and the term " chronic appendicitis " may properly cover both conditions. Among the rarer types there may be mentioned the actinomycotic and the tuberculous appendicitis. The latter undoubtedly represents a much more frequent variety than is generally assumed. Tuberculous appen- dicitis has not infrequently been demonstrated on the autopsy table as a participating manifestation of general tuberculosis. In connection with peritoneal tuberculosis it has not been observed so often (Fig. 7). The following cases of this type seem to me deserv- ing mention : Case I. — A boy, eight years of age, suffering from the caseous form of peritoneal tuberculosis, which was extensive and well marked. I found a retroperitoneal caseous stratum of the thickness of an index finger; and laparotomy revealed diffuse tuberculosis of the peri- tonaeum, intestine, and mesentery. On the basis of the appendix, which was deeply imbedded in adhesions, there was a cheesy focus of the size of a cherry. The patient recovered from the effects of the extensive opera- IS APPENDICITIS A SURGICAL DISEASE? 17 tion, which consisted in the thorough removal of the foci, but four weeks tliereafter he succumbed to general tuberculosis. Case II. — In a girl of thirteen years, in whom ex- ploratory laparotomy had revealed tuberculosis peri- tonei (light ascitic form), a tuberculous appendix was discovered. The patient, being of a rather delicate con- stitution, had complained of pain in the hypogastric region more than a year before the operation. Various members of the fraternity had diagnosticated dyspepsia, stomachal catarrh, chlorosis, endocarditis rheumatica, etc. Six months before the operation was undertaken the patient was taken sick, having swallowed a large quantity of lemon kernels. According to the statement of a most reliable colleague, the patient's symptoms had then consisted in nausea, pain in the right iliac fossa, fever, and meteorism, so that the diagnosis of appendi- citis had been made. The treatment was expectant. After two weeks the acute symptoms disappeared, but an exudation of the size of a man's fist remained in the right iliac fossa. Pressure there yielded a slight pain- ful sensation. The abdomen was distended; there was constipation; nausea and fever were absent. The ex- plorative laparotomy, performed in the linea alba, showed an innumerable quantity of nodules, ranging from the size of a pinhead to that of a pea, disseminated over the peritongeum. The apex of the appendix, which was thickly adherent to the right ovary as well as to the colon, showed three nodules. In the small pelvis were a few teaspoonfuls of light serum. Eecovery took place without reaction. Six years have elapsed since, and the patient has remained perfectly well. But there is undoubtedly a primary form of tubercu- lous appendicitis, and I trust that the daily progressing capacity for recognizing the various types of appendi- citis, which is gained and trained by the autopsy in vivo, will soon furnish much more abundant knowledge of it. I can not help thinking that in former years. 18 IS APPENDICITIS A SURGICAL DISEASE? when my experience in appendicitis was more limited, I have operated upon cases which gave me a suspicion in this direction; but various unfavorable circumstances prevented a sufficiently thorough examination into the possibilities of tuberculosis. Eecently, however, I had a chance to examine and to operate upon two well- marked cases, which seem to me of interest. Case III.- — A girl of two years was seized with slight peritoneal symptoms on October 27, 1897. Ac- cording to the family physician's report, the ileo-csecal region had been particularly sensitive on touch. Treat- ment consisted in opium and ice bag. The elevation of temperature, as well as the meteorism and the tympa- nitic sound, soon disappeared again, but a slight nausea persisted. Finally, the patient had nearly fully recov- ered, when suddenly, on JSTovember 17th, she became seriously affected with peritoneal symptoms. There was intense vomiting and persistent obstipation, as well as an elevation of temperature. Soon thereafter collapse supervened, so that intestinal constriction caused by adhesions, such as often develop after peritonitis, was thought of. November 18th I found the following state present: Poorly nourished child, showing the well-marked symp- toms of collapse. Pulse, 160; temperature normal; meteorism. A dull area, comprising the whole right iliac fossa, was clearly distinguished from that of the tympanitic abdominal sound. Diagnosis. — Gangrenous appendicitis after previous simple appendicitis. Immediate operation at St. Mark's Hospital. After having opened the abdomen in the ileo-ca3cal region the intestine was found to be of a dark-red color and covered partially with fibrinous exu- dation. Between the anterior surface of the caecum and a loop of the jejunum was a fresh adhesion, which caused the jejunum to bend in to such an extent that it could easily explain the obstruction. The adhesions were IS APPENDICITIS A SURGICAL DISEASE? 19 loosened under great difficulties, the surfaces bleeding profusely. Now, between this area a thick string, reach- ing from the caecum to the spinal column, having about the size of a man's thumb, was brought into view. After being shelled out from the surrounding tissue, this string proved to be the appendix, surrounded by numerous glands. In the adjacent portion of the jeju- num small nodules, from the size of a pinhead to that of a lentil, were found. The anaemic, yellowish appear- ance of these nodules contrasted strongly with the dark red tint of the intestine. Iodoform gauze packing. Fatal termination, five hours after operation, imder sj^mptoms of grave collapse. Examination of the lacer- ated appendix revealed the presence of a small caseotts focus in the thickened wall. Altogether, fourteen glands had been removed, three of which had undergone cheesy degeneration. The presence of tuberculous ba- cilli was not demonstrated, but the macroscopical con- ditions were so well developed that there could hard- ly be any doubt as to the presence of tuberculosis. No abnormities were found in any other organ of the body.- Case IV. — A man, twenty-six years of age, of a very delicate constitution, highly anaemic, suffered from disturbances of the stomach and intestine for years. Last year one of his two brothers died from pulmonary tuberculosis ; the other one has recently had haemoptysis. The painful attacks, which could be localized above the large curvature, and which took place spontaneously as well as on pressure, together with the presence of pyrosis, nausea, hyperacidity, and obstipation, pointed toward the existence of a stomachal ulcer, although hsematemesis was absent. All these symptoms yielded pretty quickly after the usual treatment for gastric ulcer was instituted. At the end of November, 1897, there were renewed pain in the right iliac fossa, fever, vomiting. The family physician diagnosticated ca- tarrhal appendicitis. The treatment consisted in ice bag and opium. Two weeks later the patient was again 20 IS APPENDICITIS A SURGICAL DISEASE? able to get up, but he failed to recover completely. There were also slight symptoms characteristic of stom- achal ulcer. In the middle of December he had a second violent attack of the same kind as in November. Medicamentous therapeusis again. After a few days apyrexy, with renewed disturbances in stomach and in- testine. On December 25, 1897, after being admitted to St. Mark's Hospital, the patient showed a moderately dis- tended abdomen, tenderness in the pyloric region, and well-marked pain in the right iliac fossa. Eesistance and dullness correspondingly. Diagnosis. — Chronic appendicitis. On December 26th oblique incision in the symphysis-rib line. The omentum, which is found covered with small nodules, tightly adheres to the csecum, so that it must be divided to permit access to the appendix. Situated crosswise toward the spine the appendix is found imbedded in glandular tissue, indiscriminably changed into a hard band. Great technical difficulties presented themselves in shelling out the glands, which had partially undergone caseous degeneration. The microscopical examination, while in favor of tuberculosis, did not discover bacilli, nor did the fgeces contain any tubercular bacilli. I availed myself of the opportunty of the intra-abdominal examination of the stomach to make a careful search, but neither by inspection nor palpation could I find any- thing abnormal. The patient recovered slowly. Now, four months after operation, he has a mod- erate appetite, and is free from fever and pain. He is still very anaemic, but there are no positive objective signs of any disturbance. Whether ulcus ventriculi really existed in this case I do not regard as proved. Without denying the possi- bility of it, I am inclined to consider all the more or less vague stomachal symptoms as indirect expressions of the diseased appendix, the ulcerative process perhaps IS APPEiNDICITIS A SURGICAL DISEASE? 21 having existed for a long time without causing well- marked local manifestations. In regard to the study of actinomycotic appendicitis, which I never had a chance to observe, I refer to the ex- cellent essays of Barth, on abdominal actinomycosis {Verhandlung der freien Vereinigung der Chirurgen Berlins, 1890, Jahrg. 32, S. 29) ; Partsch, on human actinomycosis {Sammlung Jclinischer Vortrdge, S. 306, 307) ; Lanz, on perityphlitis actinomycotica (Bern, 1893) ; Braun {Correspondcnzhldttcr des drztlichen Vereins von Thiiringen, 1897); and Israel {Verhand- lungen der freien Vereinigung der Chirurgen Berlins, 1895, S. 115). Wherever mixed infection with pyogenic bacteria has taken place the picture of the disease is veiled, and the chances are that thus the character of this type is gen- erally overlooked, the clinical picture of it not essen- tially differing from that of common appendicular sup- purative processes. There are also carcinomatous or sarcomatous affec- tions of the appendix. In a case of intra-abdominal adenocarcinoma I was able to detect secondary nodules attached to the serosa of the appendix. In a case of fibrocarcinoma I noticed a retrograde perforation caused by carcinomatous \^ilceration, the latter having corroded serosa and muscularis, so that the mucosa could be lifted up by a probe introduced from without. On considering now the manner in which the ana- tomical changes described express themselves clinically, we at once touch the sorest point of the controversies on appendicitis. There can be no doubt that it is the ana- tomical basis alone on which a scientific standard fun- 22 IS APPENDICITIS A SURGICAL DISEASE? dament, the symptomatology of a disease, can be built. A classification of appendicitis into light, moderate, and grave cases, as is suggested by some, must therefore, even from the strictly clinical standpoint, be rejected. The law is that there must be in general a clinical expres- sion for any tissue change. The circumstance that in many cases such expressions fail to be perceived or ex- plained properly by us is no proof of their non-existence. In spite of the difficulties of diagnosis we must endeavor again and again to interpret the various complex symp- toms that present themselves more or less confusedly. It will be only after such patient, thoughtful, and re- peated effort that we shall draw in our minds any ade- quate picture of the anatomical condition of the appen- dix. Only thus shall we be able to further the under- standing of this immensely important disease. It can hardly be assumed that the anatomical changes as they were described would show a marked clinical expression from the very beginning. On the contrary, must it be imagined that this intra-appendicular crater has been silently working for a period of time before it came to the explosion of the first attack. So there is actually a more or less symptomless chronic appendicitis, the acute exacerbation of which leads our attention to the exist- ence of the disease. By considering, however, the many vague symptoms, often protracted during years, which a number of histories reveal, we should not feel justified in speaking of the absolute absence of symptoms of this preliminary process. We should, on the contrary, real- ize that we have not as yet learned to interpret these symptoms properly. How often do we find complaints of disturbances of the stomach and intestine, or of dis- eases of the liver, kidneys, or bladder! (Compare, for instance, the history of Case IV.) IS APPENDICITiS A SURGICAL DISEASE? 28 If women are concerned, such complaints are often disposed of as being of hysterical origin, and treatment of the adnexa might be undertaken, with no result of course. Likewise may a number of nervous disturb- ances, not only of the intestine, but also of the circula- tory apparatus, being caused by reflex irritation, be derived from a diseased appendix. If we compel our- selves to think of the possibility of a diseased appendix in all cases of abdominal disorder, there can be no doubt but that we shall frequently detect some clews, no matter how meagre they may be, in this state. Pal- pation and percussion oftentimes fail, but there is fre- quently tenderness, felt spontaneously as well as on pres- sure. Thus, according to greater knowledge, we could cease to speak of a kind of latent appendicitis in favor of a really existing chronic appendicitis showing but scanty symptoms. We are accustomed to use the term appendicitis as soon as there is a typical chain of symptoms, as they mark themselves more or less distinctly already in the simplest form of appendicitis (appendicitis simplex), the most predominant of them being the sudden ac- cession of intense pain, either in the midst of perfect euphoria or after a short period of indisposition. In the greater majority of cases this pain is g^radually located in the right iliac fossa. But there are cases where in the beginning it is concentrated in the epigastrium or the umbilical region. As a rule, it first occurs on the so-called McBurney's point, or at the exterior margin of the rectus muscle in the middle of a line drawn from the umbilicus to the anterior superior spine of the ilium. This most constant symptom is accompanied by ab- dominal tenderness and very frequently by nausea and vomiting. Slight elevation of temperature is also fre- 24 IS APPENDICITIS A SURGICAL DISEASE? quently present, but it may also be absent, just the same as vomiting or nausea. The pulse may be but lit- tle accelerated. Vomiting and nausea usually do not precede the pain, as in indigestion, but follow it. There is obstipation in the majority of cases, but diarrhoea is also frequently observed. In most cases a more or less marked resistance in the appendicular region can be palpated. There is fre- quently the sensation of pressing a rigid formation of the shape of a small sausage. A most constant symptom is the more or less marked dullness, which corresponds to the thickening of the swollen tissues and which does not at all necessarily imply faecal stasis as a cause. In many cases these symptoms subside after the first three or four days. But in the great majority of cases there remains much tenderness of the appendicular re- gion, and sooner or later a second attack follows, which may end in resolution again, like the first one, but may just as well assume the circumappendieular, phleg- monous, or perforative character. In periappendicitis there are virtually the same symptoms as in simple appendicitis, but they are much more pronounced. There being in fact a circumscribed peritonitis, a palpable tumor can generally be defined in the right iliac fossa. The inflammatory exudations and the serous infiltration of the sphere immediately sur- rounding the appendix naturally make the dullness more pronounced than in simple appendicitis. The stasis of the csecal contents, caused by the compression, may fur- ther enlarge the extent of the dullness. But even if the ca?cum be entirely evacuated, the dullness will persist. The tumor may undergo resolution in three or four IS APPENDICITIS A SURGICAL DISEASE? 25 days, just as in simple appendicitis, but there may as well be suppuration. In phlegmonous appendicitis we may be eon- fronted with the same symptoms during the first thirty- six hours as in appendicitis simplex or periappendi- citis, so that a differential diagnosis at this period is entirely impossible. The temperature may also oscillate between 98.6° and 103.2'' F., and the pulse need not necessarily exceed 90. There is a real chill sometimes. On account of the well-marked meteorism the tumor sometimes can not be palpated. But the reliable guide — dullness — is never absent. I am confident that in most cases the presence of appendicitis can be diagnosticated without relying on the dullness, but it should always be taken into consideration as an additional proof, and if the question of differentiation should turn up it will be of the greatest importance. I am sure that some- times it was only the dullness that led me into the right direction. Particularly where the appendix reached far down into the pelvis, a small but dis- tinct dull area above Poupart's ligament indicated the character of the disease, which, as was corroborated always by the subsequent operation, has so far never misled me. There is sometimes only half a tablespoonful of pus present, and in such cases it happened to me repeatedly that, after having exposed the upper surface of the csecum, on a superficial view apparently normal intra- abdominal conditions presented themselves, so that at first the impression prevailed as if the operation had been entirely uncalled for. But after going further down and lifting off the caecum a fibrinous membrane of moderate thickness was found, which ended on the 26 IS APPENDICITIS A SURGICAL DISEASE? psoas muscle. These fibrinous deposits often tell of an underlying exudate, palpation of which is prevented by the overlapping csecum, which, on account of its con- taining quite an amount of air, prohibits the palpating fingers from feeling a resistance. But the dull sound could not be suppressed by the tympanitic area. By pulling off the posterior caecal surface carefully and introducing a grooved director gently into the fibrinous stratum, a small amount of pus was discharged from a cavity the walls of which were created by the agglu- tination of intestine, omentum, and the inflamed non- perforated appendix. In appendicitis perforativa suppurativa the same chain of symptoms may be present as in simple appen- dicitis. In the majority of cases the vomiting may be more constant and intense, and the meteorism more de- veloped. A distinct resistance can be felt, which, how- ever, if the meteorism becomes extensive, may cease to be palpable. But in such an event the presence of an exudate, no matter how small it is, can be proved as projecting from the meteoristic area. Chills are more frequently observed than in the other varieties, and furthermore the general disturbances of the body are more pronounced from the beginning. The fever is atypical, and might as well be moderate as high. In virulent cases it might be normal in the beginning, and in benign cases at the later period. The pulse is generally accelerated, but need not necessarily exceed 90 at the early stage. All these manifestations may also subside, and pro- tecting adhesions may form around the burst appendix, which shut off the purulent contents from the abdominal cavity. If these adhesions are firm and solid, pulse and IS APPENDICITIS A SURGICAL DISEASE? 27 temperature may be entirel}' normal, because there is no absorption of pus products. Such accumulations may thus exist for a long time, the inconvenience caused by them being so insignificant sometimes that patients thus afflicted may go about for weeks, deplorable witnesses of the curative power of expectant therapy, until either a scalpel or Nature, by perforating through the point of least resistance, shows mercy. But often the seemingly incorrect manifestations are followed by those of grave sepsis with such rapidity that the fate of the patient may be sealed inside of a few hours. The appendicitis gangrgenosa in its initial stage may begin just the same way as the other varieties, so that, unfortunately, during the first twenty-four or thirty-six hours there is entire ignorance as to the significance of the process. I say unfortunately, because this ignorance generally costs the patient's life. When the peritoneal sepsis manifests itself by ab- dominal swelling, when there is constant vomiting, sometimes of a faecal character, when faces and urine are retained, the pulse goes up and the temperature down, then, of course, there is no more doubt as to the fatal significance of the case. Then it is generally not long before the face shows the Hippocratic expression, the nose and extremities become cold and clammy, and the compressible pulse points to the intoxication of the heart muscle. The tongue is usually of an intensely red color and sometimes coated. Unquenchable thirst and singultus torment the patient, and in two or three days after the onset of the attack the tragedy ends. But in the gangrenous form, as well as in the phlegmonous or perforative variety, it need not neces- 28 IS APPENDICITIS A SURGICAL DISEASE? sarily come to the physical signs of peritonitis. The abdomen may remain flat, and rapid death may occur through foudroyant sepsis. But only in a small number of cases of this kind does this plexus of symptoms mark itself so early as during the first few hours. Nothing has ever taught me the insufficiency of our diagnostic means so impressively as these terribly rapid cases, in which the clinical symptoms were in no proportion to the pathological changes, for which the surgical opera- tion could do no more than to expose the fatal intra- abdominal lesions. In honor of the medical fraternity in the native city of the appendix science, be it said here that there is a not . inconsiderable number of physicians, increasing every year, who appreciate this gloomy state of affairs to its full extent. Their experience gained in surgical, operations for appendicitis has taught them the dan- ger of a delaying policy. They fear bacteria more than they do the scalpel, and consequently they have more confidence in operative interference than in palliative treatment. It happens even not too infrequently nowa- days that in the holy ardor for the good cause there is too much good done in this direction, and that surgeons sometimes are called upon to operate when coprostasis only is present, a condition which, of course, readily yields to the most unsurgical treatment. Such hyper- activity need not disturb us. An early operation is illus- trated in the following case : Case V. — A slenderly built girl of twenty-five years, who had suffered from slight attacks twice before dur- ing last year, was attacked suddenly in the morning of April 7, 1898, with moderate pain in the right iliac fossa, which later on radiated toward the whole abdo- IS APPENDICITIS A SURGICAL DISEASE? 29 men. The physician, who was called a few hours after the onset of the pain, insisted upon the immediate re- moval of the appendix. The patient was transferred to St. Mark's Hospital, where the following state was pres- ent at 5 P. M. of the same day : The patient shows ap- parently few signs of disease. There is slight nausea and obstipation. Spontaneous pain of considerable in- tensity sometimes occurs. The rectal temperature regis- ters 37.8°, and the regular pulse is 92. Inspection of the abdomen reveals nothing abnormal. Palpation states slight indistinct resistance in the appendicular region. The same area is very tender to touch. The patient declines the operation, claiming not to be sick enough. She sits erect in bed, as it is impossible for the nurses to keep her recumbent. This position does not seem to discomfort her as long as there is interval from pain. She threatens to get up, but, impressed by the implora- tions of her intelligent relatives, she at last consents to the operation, which was performed at 6 p. m., and re- vealed the following state : The abdominal cavity is en- tirely normal. The empty caecum has even a pale-red color. While trying to lift it off, a thin, fibrinous stra- tum is discovered, which adheres to the posterior csecal surface on one side and to the peritonseum of the right iliac fossa of the other, thus surrounding the rigidly erected appendix, which has a dark-red, and on some points a grayish-yellow appearance. The thickness, as well as the length, corresponds to the index finger of a man. There are no distinct external signs of perfora- tion, but there is a well-marked foetid odor of the appen- dix even before its removal. After being removed, the canal shows a pulpy mass, consisting of pus, necrotic tissue, and blood-corpuscles, filling up its interior. The mucous membrane appears lacerated through ulceration, and a probe pushed against the lacerated points can be seen from without, the great translucency of the appen- dix wall indicating the cobweblike thinness of the por- tion of the serosa which still prevented perforation. The stump was not sewed up in its entirety. After having been dusted with iodoform powder it was sur- 30 IS APPENDICITIS A SURGICAL DISEASE? rounded with small strips of iodoform gauze. Three quarters of the abdominal wound were closed. There having been no further symptoms of infection, and the patient complaining of nothing else than hunger, the gauze is removed two days later. The small gape in the abdominal wall is drawn together above a piece of gauze by means of aseptic adhesive-plaster strings. Re- covery was uninterrupted. In view of the high pressure under which the thin and extremely translucent wall of the ulcerated appen- dix was, it could be fairly assumed that the perforation might have taken place inside of a few hours. So it was the energy of the family physician which prevented the highly virulent contents from flowing into the free abdominal cavity. I suppose that a priori a number of colleagues would have been inclined to blame this family physician because he proposed operating in this early stage. Here we are confronted with the most delicate and important point of the appendicitis question. On this obscure point, the uncertainty of the diagnosis in reference to the stage and the toxic potency of the inflammatory process, hinge all the bitter controversies as to therapy; which show an increasing rather than decreasing harsh- ness in condemning the early operation. On the basis of my own comparative clinical anatomical experience, I am forced to assume that in about half of the cases the clinical picture of appendicitis is not so well marked that any decisive conclusion can be drawn as to the status of the pathological change. That we should reach such perfection of diagnosis is most desirable, but cruel experience teaches that we have not attained it. The surgeon who, before opening the abdominal cav- IS APPENDICITIS A SURGICAL DISEASE? 31 it}', will try to picture to himself its true condition, and who afterward has a chance to compare his imagined picture with the facts, must agree with me in this con- fession of ignorance. Now the surgeon at last is compelled, in observing the return of cases insufficiently judged before operation, to the conviction that from the presence of apparently mild symptoms a decisive conclusion as to the relative innocence of the inflammation can hardly ever be drawn during the first twenty-four hours. On the surgeon the conviction is forced that in every case of appendicitis there must be an infection, and that if the infecting material has not trespassed beyond the appendix, yet it may do so at any moment. And after it has done so the power of the knife is limited. The following, being one among many, is a typical case of this kind : Case VI. — A very strong laborer thirty-six years of age suddenly noticed at 6 A. m. on January 12, 1898, in getting up, a pain in the umbilical region, which radiated toward the right iliac fossa in the course of the afternoon. The patient had always been well before, particularly so the previous evening. During the night he had slept well as usual. It was only in the afternoon of the day he was attaclved that he felt unable to work. During the night, from the 12th to the 13th, he had a sensation of augmented disconfifort and inter- mittent colicky attacks of moderate intensity. On January 13th, at 4 p. m., a physician was called in, who, in view of finding a nearly normal pulse and tempera- ture, felt justified in diagnosticating indigestion. To the administration of opium and pepsin the pain yielded promptly. On the morning of January 14th suddenly intense vomiting and distention of the abdomen set in, and onl}'' then was the suspicion of appendicitis en- tertained. After a consultation the patient was trans- ferred to St. Mark's Hospital late in the afternoon of 32 IS APPENDICITIS A SURGICAL DISEASE? January 14th. It had not been intended to operate on the patient on the same day. Merely by accident I had a chance to see this patient shortly after his ar- rival. The state present at that time was the following: A very strong man, an expression of suffering, vomit- ing moderately often; temperature, 37.4°; pulse, 112. Abdomen distended and painful to touch. The pres- ence of meteorism prevented palpation of either tumefac- tion or resistance, but the distinct dullness, emanating well defined from the tympanitic area, pointed to the presence of an exudate. I advised immediate operation. After washing out the stomach and administering a hypodermic saline infusion the abdomen was opened in the ileo-cagcal region by an extensive oblique incision. At once there sprang forth several dark-red loops of the ileum, which were covered with flocks of fibrin and cohered loosely by fibrinous membranes. On slight touch the intestine bled. Sero-pus of foetid odor pours forth between the loops. After having pulled forward the intestine, which was flooded with hot salt water, while fibrinous flocks were wiped off by means of sterile- gauze mops, the adhesions were severed. Then the in- testine was protected with hot compresses. The caecum, in order to search for the appendix, is drawn out widely, and a small focus, containing about one tablespoonful -of grayish-yellow stinking pus, is evacuated from the cavity to the right of the lumbar vertebral column. ISTow the greenish-black appendix, transversely situated toward the iliac bone, is recognized. Up to its csecal junction it is smashed with the branches of a forceps, so that ligation of it is out of question. So it is carefully removed, and the vicinity packed with iodoform gauze, after another careful revision of the csecum, done under permanent hot irrigation. Anesthesia, admin- istered after Schleich No. 1, was excellent. Great im- provement followed the operation. Pulse even, of good quality, till the following morning showed the well- marked picture of peritoneal sepsis. Fatal termination on the same evening. IS APPENDICITIS A SURGICAL DISEASE? 33 Could this patient have been saved? Probably, pro- vided he could have been submitted to operation on Janu- ary 12th, because on the 14th it was far too late, as the condition at the operation showed. But on the 12th the patient did not yet feel obliged to send for a physician. And on the 14th, half an hour before the opening of the abdomen, which revealed so grave an anatomical condition, several colleagues were undetermined whether the indication for an operation was yet present. In view of this anatomical condition it can be fairly as- sumed that gangrene and peritoneal infection had been developed as early as January 13th. The question arises now: Is the first physician to be blamed? I say, No. It is by no means necessary that a gangrenous process should manifest itself by well- marked clinical symptoms at its beginning. Why should it? Until the death of the cells is completed twelve or twenty- four hours may elapse, and even after necrosis of the cells is complete it is not at all safe to assume that the toxic elements absorbed by the lymph channels should at once make themselves conspicuous in well-marked clinical manifestations. Thus it can be seen that from the surface we can not know the gloomy mole work that culminates in the infection of the peritonjeum. Vice versa, there is no conclusion to be drawn from slight clinical manifestations as to the presence of an innocent simple form of appendicitis, when we could safely wait until the rise of temperature and other aggravations of the symptoms would indicate that a stage of higher viru- lence has come now. How beautiful, if such were the real facts ! But it is an utter fallacy. Then it is true that the carrier of the infection can be removed, but the infection of the abdominal cavity itself can not be un- 3 34 IS APPENDICITIS A SURGICAL DISEASE? done. To expect that after the elimination of the sep- tic appendix the septic peritonitis should also cease to exist, would be like the wounded warrior, who, after the bullet is extracted, is triumphant, and cares nothing for the shot canal, nor for the tissue destruction caused by the bullet. In some cases the comparison with panaritium, where the patient, besides his pain, does not necessarily feel any general disturbance, can not be helped. For this diagnostic deficiency not the medical man but medical science is responsible. No man can give more than he has. But it can be demanded that the internists should give more attention to the knowledge gained by the surgeons during their autopsies in vivo. It is not the technique of the surgeon which I have in view. No, it is the experienced surgical observer, who watches the appendix in all its ways and doings so much more closely, who sees it in all its different forms and stages, who touches and inspects it intra-abdominal- ly. The same standpoint would then force itself upon many internes, and they would cease to hold that " ap- pendicitis in general is a light disease, the treatment of which consists in ice and opium. If "exceptionally peri- toneal manifestations should present, operative treat- ment might be considered.^' I do not have in view those colleagues who disavow the surgeon a tout prix, and who extol themselves with a smile of superiority that they have cured all their cases of appendicitis by their nihil- istic modus operandi. But how many such cases termi- nate fatally without being diagnosticated properly! What would these antisurgeons say if in all these cases they had been cited before the pitiless autopsy forum ? No, I have in view those unprejudiced colleagues IS APPENDICITIS A SURGICAL DISEASE? 35 who collect notable experience from sufficient clinical material. There can be no question that such colleagues see a not inconsiderable number of cases of appendicitis recover. The statistics on such recoveries are simply overwhelming, and in some clinics even the enormous percentage of ninety is spoken of. If, however, those so-called recoveries are closely analyzed, it will be found that most of these patients who overcame simple appendicitis were not observed any further. But it can well be assumed that the appen- dix in all those " cured " cases had undergone patho- logical changes, which sooner or later caused a second or third attack. Then such a case might figure in the statistics as a case " which was cured three different times." Or the patient might have succumbed to the second attack just as well. Sonnenburg alone observed recurrence of the inflam- matory process thirty-two times in fifty-one cases, which gives a percentage of sixty-three. It seems to me that in patients who report a first, well-overcome attack, the physician is particularly ready to resort to the expectant treatment. It is only when a grave toxsemic picture develops that in his anxiety he may at last advise an operation as an ultimate resort. But then it is much too late, and the operation being un- successful, the internist believes he has added further proof to the theory that operative interference in ap- pendicitis is a fraud. The surgeon, of course, will hold altogether differ- ently, and very properly makes the proerastinator re- sponsible for the fatal outcome. But this case now swells the surgical list of casualties and the internist goes out unconcerned, while virtually the mortality 36 IS APPENDICITIS A SURGICAL DISEASE? number of this case belongs to his account. There is to be considered furthermore the large number of patients, occupying the wards of hospitals, who are ad- mitted under the vague diagnosis of peritonitis, internal obstruction, etc. How often would appendicitis be dem- onstrated if an autopsy were always performed ! If such cases terminate fatally under internal treatment they will not be credited to the appendicitis list of cas- ualties. And if such desperate cases drift into the hands of a surgeon, who, adhering to the principle that such patients have nothing to lose and everything to gain, run the great risk of an operation, there will naturally be a very small number of recoveries. So all the surgeon could do was to swell the mortality account of appendi- citis by his diagnosis, which was defined at, or rather by the operation. Suppose such a patient had died without being subjected to operation; the diagnosis of appendicitis would probably not have been made at all. It is a fact greatly to be deplored that in this country the permission of an autopsy is granted but exceptionally by the relatives of the deceased. Thus it appears no more than natural that the case should be put in the column of peritonitis instead of bur- dening internal medicine as a fatal case of appendi- citis. To refer to Case VI, in opening the peritonaeum the conviction could not be suppressed that there was no hope. Up to that date I did not see a single case recover in which the presence of serum of foul odor was noted in connection with the absence of protecting adhesions. Thus I am inclined to regard such occurrences as a kind of criterion for further revelations in the peritoneal cavity. It seems to me as if there is a particularly high IS APPENDICITIS A SURGICAL DISEASE? 87 virulence, which manifests itself partially by this macro- scopical state. Were aspiration undertaken in such a case, it might be that before operating a conclusion might be drawn from the aspirated serum to the extreme gravity of the case. But such cases take such a rapid course that there is no time for bacteriological investigation. Still, conclusions should be drawn from the direct macro- scopical state as to the dignity of the toxon. There is only one drawback ag,ainst aspiration — namely, the pos- sibility of further inoculation with the tip of the needle, which should not be underestimated, as it can not at all be compared with the aspiration of an empyema or simi- lar condition. An exploratory incision in the appen- dicular region is much less apt to spread infection than aspiration. Eegarding further dates and reports, considering the difficulties to find an adequate clinical expression for the grave anatomical lesions, I refer to my previous publi- cations on this subject — viz., On Some Difficulties in Eeference to the Early Surgical Treatment of Appendi- citis.* I may be permitted to add that the experience gained since these articles were published has only corroborated my views about the unreliability of the symptoms. \ Most cases of appendicitis do not come under the observation of the surgeon during the first forty-eight hours. Procrastination to the utmost limit before the surgeon with all his terrors is called upon is the too * Journal of fhe American Medical Associatio7i, December 28, 1896, and Zur Therapie, insbesondere dem Werthe der Friihoperation bei der Entziindung des Processus vermiformis, Berliner klinische Wochenschrift, 1896. Nos. 37 and 38 38 IS APPENDICITIS A SURGICAL DISEASE? frequent practice. And it is not only the layman; no, sometimes it is a hypersesthetically disposed colleague who dreads the sight of steel more than the abominable appearance of a bloody tinged intestine bathed in foetid secretion. This horrid intra-abdominal picture, of course, is veiled from his eyes, and therefore even from his imagination; so that he can give no attention to it. How often have I thought of the simple words of the peerless Henoch, which he spoke in reference to the treatment of dysentery : " Whoever has seen on the au- topsy table the immense destruction which the dysen- teric ulcers cause will realize why so often our whole therapy sinks into nothingness." Furthermore, it is to be remembered that from a pyappendix sometimes emanates a subphrenic abscess. Cases of this sort are described in my publication on subphrenic abscess {Medical Record, February 15, 1896, and Langenbeek's Archiv, Bd. lii, Heft 3). Abscesses in the liver, the pleura, the brain, may also be derived from appendicitis, the same as pyaemia and some lung affections, which figure as causes of death per se, while, in fact, appendicitis should be registered as such. So the statistics on appendicitis, as they are offered nowadays, can not be regarded as other than most unreliable. Only tbe most careful criticism of the cases and their further observation after a so-called well- overcome attack can do justice to the surgeon. The following resume may now be made: 1. The fate of patients operated upon unsuccessfully by the surgeon on account of extremely high virulence or undue procrastination is sealed beforehand. 2. The patients who were " cured " under medical treatment would also have recovered had they submitted IS APPENDICITIS A SURGICAL DISEASE? 39 to operation. For the small number of deaths after operation, of which reports are given once in a while^ rather the surgical novice than surgery itself is respon- sible. 3. Eegarding the practice of delaying, even among most of those who advocate surgical interference, to rec- ommend operation until abscess or gangrene is demon- strated, it must be realized that with few exceptions all such cases would finally have proved fatal under the pursuance of medical treatment. According to the calculation of some of the most eminent surgeons in the country, there are about five thousand annual deaths from appendicitis in the United States alone which could have been prevented by early operation; and this enormous number does not seem to me to be exaggerated. We thus arrive at entirely dif- ferent conclusions from those drawn from many inter- nal statistics which were collected bona fide. I trust that I do not exaggerate if I calculate that the per- centage of the fatal cases, treated expectantly or inter- nally, if followed up ad ultimum, is about thirty. This percentage could be forced down to ten, or even to five, if the custom was adopted of operating early. Is it not strange that of all the patients whom I have operated upon as early as twelve hours after the onset of the attack, none have died? Unfortunately, this chance was given to me but twenty-seven times, while among those of my patients on whom I operated forty-eight hours after the onset there is a mortality of twenty-four per cent. Why do the internists not take to heart the ex- cellent words of Striimpell, " Better too early than too late." Such golden words, coming from a distinguished internist, do more for the popularization of the surgical 40 IS APPENDICITIS A SURGICAL DISEASE? standpoint than all efforts of the surgeons themselves; just as it was only after rib resection in pyothorax was indorsed by so popular a man as Gerhardt that this operation was fully recognized by the family physician. There are yet to be considered those cases of appen- dicitis which are sent to the hospital under the diag- nosis of internal obstruction, ileus, etc., from the stand- point of euthanasia. Such cases being far advanced, differentiation is almost impossible without operation. But there are still a number of other diagnostic errors which are made by the most experienced internists and surgeons, and wbich are also cleared up by the operation only. Empyema of the gall bladder, for instance, is a fre- quent source of such error. A striking case of this kind was published by me in tlie New York Medical Journal, May 8, 1897. (Compare also Centralblatt fiir Chirur- gie, 1897, Ko. 42.) The character of the pain is regarded as one of the most valuable points of distinction in this connec- tion. In appendicitis the pain will often be localized around the umbilicus and epigastrium to establish itself at last at the right iliac fossa, while in cholelithiasis the pain remains fixed in the epigastrium and radiates at the same time toward the scapula. Thus the point which is found sensitive on palpation would correspond to the respective regions where the anatomical change has taken place. But to this reflection the objection has to be raised that the subjective localization of pain and the localization of the anatomical lesion do not always correspond, as it has often been proved in simi- lar clinical observations which were followed by opera- tion and revealed the pathological derangement at a IS APPENDICITIS A SURGICAL DISEASE? 41 distance from the painful region. Considering the pain as trustworthy, it must be remembered, as explained above, how ditferent the situation of the appendix is. It is found far down in the true pelvis and so high up that in an inflamed state it can well be taken for a deeply situated gall bladder, the latter possibility not being so very rare (compare case mentioned above) that, on the other hand, a diseased gall bladder could not be taken for a thickened appendix. Adding to this the fact that in cholelithiases icterus is more frequently absent than present, we have to confess that in the ma- jority of cases we have to relinquish this symptom, which otherwise is of such immense value for the distinc- tion. The type of the vomiting is also unreliable. It is regarded, as a rule, that in the early stage of appendicitis there are vomiting attacks, which decrease again after a while and later on increase again, while in gall-stone colic there is continuous and frequent vomiting. Taking it for granted that this is so in the majority of cases, it can not be denied that all the points described are not determining, and the ultimate decision in such cases will only be reached by opening the abdomen. Pyosalpinx is also sometimes confounded with appen- dicitis. As both affections indicate laparotomy, a diag- nostic confusion is fortunately not of great practical significance. There is, however, a difference of opinion as to whether such confusion is excusable or not. Some say that nothing is easier than to ascertain the presence of a swelling situated laterally from the fornix by bimanual palpation. Such swelling in connection with the immobility of the uterus and a history of disturb- ances in the sexual sphere could only be interpreted as 42 I'S APPENDICITIS A SURGICAL DISEASE? pyosalpinx. Reliable differential conclusions could also be drawn froiu the character of the temperature as well as from that of the pains and their radiation. I do not hesitate to confess that this error has happened to me twice, when I have been unable to palpate the pyosalpinx even after an anaesthetic was administered, the uterus having been slightly movable and the annexa having appeared to be normal. The explanation was that the tumor had been pushed upward. On the other hand, it can easily be conceived that in a case where the appendix reaches far down a pyo- salpinx is diagnosticated and a pyappendix is found at the operation. And it also happened to me several times that I was asked to perform an operation for appendi- citis where salpingitis could well be distinguished with- out performing an abdominal section. (Compare cases in my article on Appendicitis, Berliner Minische Wo- chenschrift, 189G, No. 38.) In five laparotomies performed for pyosalpinx I have found the appendix adherent to the tube or ovary. There the appendix was always removed also. On exam- ination, cicatricial strictures were found in each of these appendices, from which fact it can certainly be assumed that it had participated in the inflammation of the annexa. It is also not excluded that an appendicitis had been the original cause of the inflammation of the annexa. Three times I have found tube, ovary, and appendix glued together in a colloid mass, undoubtedly the late 3onsequence of old inflammatory processes. There I was compelled to remove a considerable portion of the much- thickened peritongeum in order to be able to proceed radically. IS APPENDICITIS A SURGICAL DISEASE/ 43 Case VII. — In the case of a •woman of fifty years of age on whom I performed resection for intestinal car- cinoma the following peculiar condition was found (see Fig. 8) : A tumor originating from the caecum, of the size of a man's fist, and easily palpated from with- out, reached from the median margin of the caecum to the end of the ileum. Above this tumor there was a dermoid cyst ( Cy. ) , a little larger than an apple, and at- tached to the tubal wall ; it adhered tightly to the peri- tonaeum above and toward the renal region. It con- tained the characteristic pulpy mass and hairs, cartilage, and teeth. The lower end of the appendix as well as the tube on the opposite surface of the cyst, as is evi- dent from Fig. 8, adheres extensively to the der- moid cyst. (T represents the fragment of the tube and A the fragment of the ovary.) By performing a circular resection I succeeded in removing the different Oy Ov. Care. ' - A. L'iecuin. Fig. 8. — Appeudis adherent to dermoid cvbt. tuue, and ovary. masses in their coherence, as illustrated by Fig. 8. In this case strictures could be demonstrated in the appen- dix also. Considering the adhesions, it could safely be assumed that inflammatory processes had been present in and around the appendix. To these probably could be traced the attacks of pain which the patient suffered once in a while, and which had urged her to the opera- tion. During an attack of this kind the picture of her 44 IP APPENDICITIS A SURGICAL DISEASE? cgecal tumor would have been veiled, and so the thought of appendicitis could well have arisen. The carcinoma itself did not seem to have caused any direct disturb- ances, the tumor neither having narrowed the intestinal lumen nor had signs of breaking down manifested themselves. It may further deserve mention that, in view of being able to displace the carcinoma upward and backward, and also considering the good appearance of the patient,, the possibility of the presence of a float- ing kidney had been borne in mind. In this connection it should be remembered that periodical hydronephrosis, caused by a right floating kidney, which may exist together with fever, vomiting, and pain in the right side, could give rise to confusion with appendicitis. In comparing with this case the views of Osier,* I think that the mobility of the tumor should decide the question in favor of the affection of the kidney. I have twice been guilty of a confusion with a right- sided hsematosalpinx. In both cases the disease had begun with sudden pain in the side and with mod- erate fever and vomiting in women of middle age. Both patients recovered and have certainly not noticed any disadvantage from the wrong diagnosis. Extra-uterine pregnancy also presents itself some- times, and, after peritonitis has manifested itself, makes the meteorism answer to the question of inceptive causes just as difficult as in the diseases of the gall bladder, de- scribed above, in which laparotomy had to give the last word of explanation. In extra-uterine pregnancy the absence of menstruation, in connection with the general symptoms of pregnancy, the bloody vaginal secretion, * Principles and Practice of Medicine^ New York, 1894, p. 720. IS APPEXDICITIS A SURGICAL DISEASE? 45 and the sensitive tumor in the fornix have to be mainly considered. In general, it may be said in reference to the dis- tinction between appendicitis and diseases of the an- nexa, that the pain, the fever, and the signs of peritonitic irritation are common to both, but that in the latter the progressive tendency of extension to the peritonaeum is usually lacking. Thus the consensus of symptoms in dis- eases of the annexa is not so grave. But we must not for- get that sometimes, as already said, in the early stage of even the gravest forms of appendicitis there are no reli- able signs of peritonitic irritation. For the disease of the annexa the gonococcus is mainly responsible. The gonococcus is a bacterium of comparatively low virulence. This becomes evident by the fact that gono- coccus pus, finding its way into the peritoneal cavity, fails to produce general infection. This explains why the peritonitis, caused by it, generally takes a favorable course. If, during a laparotomy performed for pyo- salpinx, the misfortune of the bursting of the pus sac happens, so that pus is freely discharged into the peri- toneal cavity, it can be positively ascertained by micro- scopical examination in a few minutes whether there is gonococcus or streptococcus or staphylococcus pus. (See my Manual of the Modern Theory and Tech- nique of Surgical Asepsis. Saunders, Philadelphia, 1895.) If the innocuous gonococcus diplococci are found, the abdominal cavity may safely be closed, while in the latter case the iodoform-gauze tampon is to be preferred. But all these points are of only a general nature and in a special case appearances are often deceitful. It is also to be considered that the proof of benignity 40 IS ArPENDICITIS A ISURGICAL DISEASE? is often furnished only after the process has taken its course. But in appendicitis there is no time for de- lay. Immediate action is required here; the patient not profiting after the lapse of a few days, we find that there is no hope for him any more. Had we given him the practical benefit of our diagnostic doubt in time, he would probably have been saved by an operation. As said above, the surgeon is not infrequently re- quested to operate for alleged internal ohsti-uction, for invagination, intussusception, volvulus, or for adhesions of inflammatory or congenital origin, in which the in- testine is caught as in a mouse-trap. In such cases appendicitis is often found. Considering the great sim- ilarity of the symptoms — viz., the suddenness of the at- tack and of the pain, the vomiting, and the subsequent peritonitis — the confusion is obvious. Here it must also be considered that in internal obstruction the pain concentrates nearly never to the right iliac fossa, but more or less to the region from which the lesion in question itself originated. Furthermore, it should be borne in mind that in these cases the vomiting is nearly constant from the early stage on, and soon assumes a 'fasculent character, .which hardly ever happens at the early stage of any type of appendicitis. Meteorism also supervenes only late in appendicitis. In intussusception, a painless tumor can usually be palpated. Fever is generally absent. In volvulus, digital exploration by the rectum often gives the desired information. In mouse-trap eases there is generally a history of a preceding peritonitis. The difficulty of distinguishing between internal ob- struction, gallstone ileus, and appendicitis was illus- IS APPENDICITIS A SURGICAL DISEASE? 4.7 trated b}' me in a fatal case, (l(>scribcd in tlic New- YorTcer medicinische Wochenschrift, February issue, 1897, p. 113. Sometimes, also, it is difficult to differentiate be- tween appendicitis, renal and gallstone colic. In renal colic it is important to know that the pain on pressure is mainly limited to the lumbar region, there is hardly ever any vomiting, and the pain gravitates toward the scrotal and rectal region. Vesical tenesmus and hsema- turia are also frequently present. Ureteritis may also be confounded with appendicitis, especially if it becomes combined with cystitis and ne- phrolithiasis or tuberculous kidney. The presence of blood and pus in the urine and the chronic course should, however, be conclusive in favor of ureteritis. My experience in a recent case of nephrolithiasis, which caused ureteritis shows, however, how these symptoms may be veiled. Case VIII. — A well-built man, thirty-five years of age, who had always been well until about a year ago, began to suffer slightly from occasional digestive dis- turbances. On October 1, 1898, while at work, he noticed a pain of moderate intensity in the right iliac fossa. AA^hen, a few hours later, nausea and fever set in, medi- cal treatment was obtained, which, so far as could be ascertained, was of a palliative character. On the following day the pain and nausea disappeared and on October 3d the patient resumed work. On the 10th, after having passed a whole week without discomfort, he was suddenly attacked with intense pain in the same re- gion. Under the administration of opium and the use of an ice-bag he was relieved again for a short time, until, on the 11th, the symptoms assumed a grave char- acter. The presence of a tumefaction was discovered then by the attending physicians, and the diagnosis of appendicitis made. -l-S 1« APPEiNLKJlTlS A SURGICAL DISEASE? On the 14th, when the patient was referred to St. Mark's Hospital for operation, the following state was found: The emaciated patient's general condition made a grave impression. Little pain was complained of. Its character was hy no means colicky, and it radiated some- what toward the umhilicus. This was not regarded as a pathognomonic symptom, since the absence of intense pain could be exjjlained by the narcotizing influence of the toxines jjresent. The bowels were constipated, but the passage of the urine was normal. Vomiting was moderately frequent. The pulse was 130 and feeble; the temperature was 101.2° F. ; and the respirations were 36. The abdomen was distended and slightly painful to the touch. In the right iliac fossa tumefaction and corresponding dullness were found, which filled the iliac fossa and extended anteriorly to the mamillary line. The lumbar region showed nothing particular. Exami- nation of the highly saturated urine showed nothing ab- normal; especially were no blood casts or pus detected. It is obvious that, in view of the presence of these symptoms, so characteristic of appendicitis, the diag- nosis was positive. The operation was performed on the same day, after saline infusions had been liberally ad- ministered. The incision was made in the symphy- sis-rib line. When the peritonaeum was divided, slightly odorous pus of thick consistence and gray-yellowish color was discharged. Now a large cavity could be in- spected, the median wall of which was formed by the caecum, to which a normal-appearing appendix was attached by loose adhesions. In the bottom of the cavity a mass of necrotic tissue was found in which a hard stone of the size of a large filbert was discovered. Its shape was elliptic and its surface granular. Examina- tion showed it to consist of a nucleus of uric acid with oxalate layers around it and a superficial coat of earthy phosphates. The situation of the ureter could not be made out distinctly among the detritus. Examination of the pus revealed nothing particular. The cavity was drained with iodoform gauze. Recovery was uninter- IS APPENDICITIS A SURGICAL DISEASE V 4,9 rupted, and the patient was discharged from the hos- pital a month after the operation. No urine ever es- caped through the wound. It seems to me that the calcuhis had found its way from the renal pelvis into the right ureter, where, on account of its large size, it was arrested. There it caused considerable irritation and inflammatory changes, producing the formation of adhesions in which the cal- culus became impacted. This happened probably at the time the patient noticed the first pains, on October 1st. A few days later, probably synchronously with the second attack, perforation with abscess-formation took place, the adhesions then being so dense that they pro- tected the ureteral perforation, thus preventing the escape of urine from there. In regard to the absence of hsematuria, the possi- bility should not be excluded that during the first epoch it might have been present unnoticed. During the second attack it was certainly absent. The normal pass- ing of the urine and the absence of real paroxysms of renal colic are most remarkable in this case. Especially in septic cases the signs of nephritis are often found if the lu'ine is carefully examined. Pus in the urine was observed by me seven times, undoubtedly the conse- quence of septic absorption. Only three of these cases recovered. How coxitis can be taken for appendicitis has been explained above. If there is any doubt, the Rontgen rays will always throw light. There are reports on typhoid fever in the first week, when moderate fever, slight pain in the right iliac fossa, and meteorism were present, having been confounded with appendicitis. But the history, the general charac- 4 50 IS APPENDICITIS A SURGICAL DISEASE? ter of typhoid fever, the typical temperature, should permit of no doubt. Eegarding perforation of a typhoid ulcer, it can be maintained that the symptoms of a per- foration peritonitis are similar to those produced by a perforative appendicitis. But such an event never hap- pens before the third week in typhoid fever, so that from the further course conclusions can be drawn from this fact. Since it became known that with few exceptions all the forms of inflammation, vaguely termed typhlitis, perityphlitis and paratyphlitis, were identical with the different types of appendicitis, the impression has pre- vailed among some ultra-radically inclined colleagues that typhlitis has gone out of fashion entirely. But that there are real cases of stercoral typhlitis can not be doubted, the rarity of the cases being of course admitted. At the early stage the diagnosis is difficult, since the symptoms are identical with those of appendicitis. The only distinguishing diagnostic factor would be furnished by the doughy consistence of the tumor. Shrady * has sometimes been able to produce indentation, which phe- nomenon can be plausibly explained from the faecal com- position of the contents of the tumor. They should, of course, not be confounded with cases of simple co- prostasis, as happens frequently. That such cases of coprostasis are always easily cured, be they treated under their proper name or under the false diagnosis of appen- dicitis, by the omnipotent laxative, does not need fur- ther argument. A most remarkable case which had been operated upon for appendicitis originally, and in which I found * Medical Record^ January 6, 1897. IS APPENDICITIS A SURGICAL DISEASE? 51 an intact appendix by performing laparotomy later, is the following: Case IX. — A strong man of forty years of age fell ill on January 15, 1896, with intense pain in the region of the umbilicus and of the right iliac fossa. Nausea and fever were also present. In spite of the gravity of the symptoms the patient walked about until January 29th without consulting a physician. In a septic condition he was then admitted to St. llark's Hospital. There a small, frequent pulse, high tempera- ture, tumefaction, and a corresponding dullness in the right iliac fossa were noted. The diagnosis was appen- dicitis perforativa. The operation, which was per- formed at once, revealed partial gangrene of the caecum. There was grayish-yellow pus of an offensive odor, but without a serous admixture. The appendix was not found. After the operation the patient recovered some- what, but soon fell into a state of somnolence. The temperature wavered constantly, and the pulse re- mained between 120 and 150. Repeatedly abscesses, which formed near the caecum between intestinal loops, were opened. Then there was always slight temporary improvement, soon followed again by the recurrence of septic symptoms, so that we gave the patient up at last. In the meanwhile an ectropion of the extent of the palm of the hand had formed (Fig. 9). Eisking a last effort under ether aneesthesia, I, in exposing the upper wound margin, detected a small abscess, which reached upward to the liver. After having discharged the ab- scess, the presence of which had not at all been sus- pected by me, the patient recovered rapidly, so that I could proceed to the closure of the enormous ectropion on March 20th. After having prepared the patient thoroughly for several days, and after having packed the afferent and deferent ostia prophylactically, I sev- ered the intestine extensively from the adhesions, this being particularly difficult posteriorly. The freshened intestinal wound margins were coaptated minutely and 52 I« APPENDICITIS A SURGICAL DISEASE? sewed up continuously after tlio Lembert-Czerny meth- od. There was perfect union, which seems to be mainly due to the most extensive separation of the adhesions. Many surgeons warn us against resection, as in most eases a little, promising procedure, and recommend en- tero-anastomosis instead. The patient had defsecated through his abdominal opening ever since the operation on January 29th. Af- FiG. 9. — Intestinal ectropion after gangrenous typhlitis. ter the enteroplasty he defecated by the rectum. Only once, ten days after the last operation, transitorily faeces were found in the wound. On the following day per- fect obliteration had taken place and the patient enjoys the best of health ever since. After the separation of the intestine was perfected, an intact appendix was dis- IS APPENDICITIS A SURGICAL DISEASE? 53 covered slightly adherent to the peritonaeum. Examina- tion showed the mucosa to be normal. Therefore it may be assumed that originally the gangrenous process was confined to the wall of the caecum. Among other confusions, the psoas and lumbar ab- scesses may yet be borne in mind, the recognition of which should not cause much difficulty. in view of their slow growth, the deformity, the absence of peritonitic manifestations as well as of grave initial symptoms, to- gether with the history. In regard to the diagnostic difficulties in peritoneal tuberculosis, I refer to history jSTo. 2. That diseases of the pancreas have been mistaken for appendicitis can be appreciated better than their con- fusion with malarial disease, influenza, or pneumonia. Arriving now at the salient point of the appendicitis question, the therapy, we still hear the unceasing battle cr}', " Here opium, here scalpel ! " If we realize the in- fectious and progressive nature of appendicitis, as I tried to emphasize it in the introduction of my article, we shall not expect a cure from internal treatment; while by modern surgical technique we are able to reach the focus of disease and to render it innocuous at its early stage. I must therefore answer the question, " Is appen- dicitis a surgical disease ? " in the clear affirmative. This does not mean. that appendicitis should altogether be turned over from the hands of the internists to those of the surgeons. There is no fear of that, because the appendicitis public also has a word to say in this mat- ter. In practice a case of appendicitis never goes direct- ly to the surgeon, since the patient himself never makes the diagnosis appendicitis, but he suffers from the omi- nous pain, which, more than his feelings of general ma- 54 If' APPENDICITIS A SURGICAL DISEASE? laise, causes him to see his family physician. What he demands from him first is that he should cure his " belly- ache." Now, this family physician should realize that he is confronted with a disease of absolutely surgical char- acter, and that, unless he can cure it surgically him- self, he should immediately call in the aid of a surgeon. In this manner most surgical cases do not drift into the hands of the surgical specialist, but nearly always into those of the general practitioners, whose greater or lesser skill in surgery turns the scale, whether or not the case really requires further deliberation with a surgeon. So we find it natural that in fractures the family physician is called in first. So long as he trusts he can master the case, he would be blamed for summoning a surgeon. But there would be much more reason for blaming him if he did not fully realize that he had to deal with a strictly surgical disease, which he must treat after true surgical principles. Should he encounter any difficulties in the treatment of the fracture, there is nearly always enough time to take a surgical specialist into council and to conduct further treatment accord- ing to his advice. But in appendicitis success is mainly determined by immediate interference, and the right to interfere is his only who is competent to execute the cure technically. That there is plenty of space for cooperation of the family physician, who is conversant with a great many matters which the surgeon again does not know, and whose knowledge is to the surgeon's and the patient's greatest advantage, is beyond question. It shall not be denied that immobilization of the intestine by opium, after a preceding evacuation of IS APPENDICITIS A SURGICAL DISEASE V 55 the lower intestinal portion by an enema, will pro- duce a perfect palliative success in a large number of cases of appendicitis. But a real cure can be expected as little as from the mere adoption of the splint in phlegmon of the hand. The administration of opium for the purpose of arresting intestinal peristalsis, agree- able as it is for the patient, has the most deplorable consequence that it lulls not only the patient but also the attending physician into a feeling of security, from which both are aroused most cruelly by the early appear- ance of peritonitic symptoms. Therefore the adminis- tration of opiates should be advised against most ener- getically before a distinct diagnosis is arrived at. After the diagnosis is made, the administration of opium is rational, even if immediately afterward the operation is performed. However light the clinical expression of appendi- citis may be, and liow much it may appear to be in favor of a speedy temporary recovery, the operation is always justifiable. As the strength of the infection can never be known with certainty from the beginning, it appears to be wiser to take each appendicitis seriously. Among two evils the smaller should be chosen, and operation is the smaller evil. The assumption of a simple appendicitis with a tendency to spontaneous resolution is mostly made by a comparatively untrained observer. If there be nothing more than a simple appendi- citis, I can not see how in the hands of an aseptically trained surgeon life should be jeopardized by simple appendectomy, even if it should prove to have been un- necessary. But if there is perforation or gangrene in the nascent stage, the early operation positively saves 56 IS APPENDICITIS A SURGICAL DISEASE? the life of the patient, who otherwise would probably succumb to internal or expectant treatment. Thus at the early stage the surgeon is the boss, so to say, while in the late stage he is an adventurer, who is successful, yet only once in a while, under extraordinary circumstances. But times have passed when celebrated surgeons found it expedient to write books on " luck in surgery." If the attending physician does not care to be con- verted to this standpoint he should at least regard it his duty to explain the nature of the disease to his patient, and to leave it to him, whether, after he passed his attack, he had better have his appendix preserved in the alcohol bottle than in his iliac fossa, where it represents an explosive stuff which may lead to a catas- trophe any moment. He can surely depend upon en- countering a second or third attack after having been through one, and there is little doubt that he has to suc- cumb to one of these attacks some day. Considering that under the auspices of asepsis the mortality of simple appendectomy is nearly nil, every colleague should regard it his duty, no matter to what colors he has sworn, at least to communicate these facts to his patient. Up to date I have performed simple appendectomy seventy-four times without a single death. I know that there are several surgeons in this city who could report a much larger number of similar cases with the same gratifying result. Even extensive adhesions should not cause disturb- ances in the course of the wound treatment. And these adhesions are, as a rule, only present if there has been more than one attack, as after one attack generally only slight adhesions are detected. IS APPEiXDICITlS A SURGICAL DISEASE? 57 As alluded to above in the pathological part of this article, most patients who have gone over one attack of appendicitis suffer more or less from disturbances of stomach or intestine, which becomes worse on the slight- est provocation. The fear of injuring themselves forces a regimen upon them which impairs their nutrition and becomes unendurable in the end. Thus, even when well-marked local symptoms fail to show themselves, a picture similar to hypochondriasis develops. If the appendix is removed in such patients, one is surprised to see how at one swoop all these symptoms disappear, and the jDatient becomes an entirely new man. In drawing conclusions from what has been said we may condense them into the following theses : 1. Appendicitis is a surgical disease and should be treated surgically as soon as the diagnosis is made. 2. So long as no physician is able to ascertain the grade of bacterial virulence at its early stage, the safest therapy consists in the early removal of the appendix. 3. If the patient or his advisers should object to operation, the expectant immobilization treatment should be instituted, and, after the attack is over, the necessity of appendectomy thereafter should be made clear to the patient. ^ 4. Should the conditions surrounding the patient be of an extremely unfavorable nature, should no com- petent surgeon be obtainable, and should there be other difficulties, the risk of the expectant treatment should be preferred to that of a badly performed operation in an acute attack. Then, if he should pass over the attack, the patient should submit to appendectomy later. 5. Considering that the mortality of simple appen- 58 IS ArrENDICITIS A SUKGICAL DISEASE? dectomy is almost nil, its performance should be urgent- ly recommended to the patient after the first attack. I well realize that doing this will often cause the greatest difficulties to the family physician. So many prejudices, so many family considerations obtrude on him that he will often fail to have the courage to contend with the whole weight of his personality for these theses, although he is convinced of their scientific truth. Nor will I throw a stone at the family physician who, jurans in verba magistri, intoxicates himself with the sphere music of internist statistics, and shows the surgeon, who advises operation, sneeringly the list of dissuading internists. I simply deplore things as they are, and add my share to the better appreciation of a disease which, to its full extent, is recognized by none of us yet. But I may hope, with those who agree to my views, that the day will come when its surgical prospec- tive will be everywhere acknowledged. But what we are entitled to demand imperatively from every one who undertakes treating appendicitis is, that he learn enough of the pathology of the appendix to appreciate from the beginning the risk which the pa- tient runs during his acute attack, and that information, should be given accordingly. Penzoldt well says of appendicitis : " In none of these cases can a gloomy sensation of gravest responsibility be suppressed. The physician who does not know this sensation does not know the nature of this disease." The technics of simple appendectomy, as I perform it in recent years, is the following : First of all, I make it a principle to put the patient in bed for at least two days and to give him only fluid diet during this period. After admission to the hospital IS APPENDICITIS A SURGICAL DISEASE? 59 he first takes one or two tablespoonf uls of castor oil ; on the following day, and on the morning of the opera- tion, an enema is applied. For thorough prophylactic disinfection the iliac and pelvic regions are shaved. While a warm bath is taken, a rigid scrubbing with green soap is done. Then a poultice of green soap is applied to the right lower abdomen, which remains twen- ty-four hours. I regard this an essential factor for the disinfection of the skin, because I do not believe that under ordinary circumstances the epidermis, which shel- ters a multitude of pathogenic bacteria, can be ren- dered sterile by the usual methods of disinfection, which generally are not carried out for more than from ten to fifteen minutes. A period of twenty-four hours gives the soap a chance to permeate the epidermis thoroughly, so that scrubbing on the following day is much more effective. Sometimes, indeed, the poultice macerates the .epidermis so that it can be wiped off easily. Shortly before the operation the skin is scrubbed with gauze mops dipped in alcohol, the use of which is more im- portant than that of any antiseptic drug, as it dis- solves the fat of the skin. Bacteria so long as they are imbedded in fat will not be influenced at all by the strongest antiseptic medicament. I always attempt to have the protecting sterile napkins as i near the wound margin as possible, fastening them there with small miniature forceps, so that all subsequent manipulations, especially ligation and suturing, can be done on a safe and sterile field. I have repeatedly seen surgeons who had taken minute care in their aseptic preparations wallow around the intestine on the abdominal skin in the roughest manner while manipulating it after it was taken from the abdominal cavity. 00 IS AP1'E]^JD1C1TIS A SURGICAL DISEASE? The operator, as well as the assistant engaged at the wound, and the one who hands the instruments, wear sterilized linen gloves. So long as we are not in posses- sion of an absolutely reliable method of rendering the hands of the operator indisputably sterile, they should have a reliable aseptic protection, even though this may interfere with the elegance of the operation. After the abdomen is opened the gloves might be taken off for the minute work on the intestine. In pus cases they may be taken off after the abdomen is well cleaned. (On the employment of gloves, compare the writer's manual of the theory and technics of surgical asepsis, Saunders, Philadelphia, 1895, p. 94.) The procedure of making the skin incision is of greatest importance. After having experimented with various methods, I found it most opportune to modify McBurney's method in making a long incision in the direction of the fibres of the external oblique muscle in such a manner that its centre fell into the middle of the line drawn from the symphysis to the anterior end of the eleventh rib. The incision begins about three fingers' breadth above the symphysis, and ends in the same distance from the anterior end of the eleventh rib in the line described (Fig. 10). Now the fatty superficial fascia and the fascia of the external oblique muscle are divided. The rectus muscle is not concerned, there being no fear of injuring its sheath, which would cause little, yet troublesome, hemorrhage, and also a series of disturbances in the course of the wound treat- ment, inasmuch as the wound margins could only with difficulty be approximated to each other. Now the fibres of the external oblique muscle are carefully separated, which can be done easily with the IS APPENDICITIS A SURGICAL DISEASE? 61 handle of the scalpel, considering that the direction of the incision corresponds to that of the muscular fibres. If the margins are kept asunder by broad hooks, it is generally possible to separate the underlying fibres of the internal oblique and of the transverse muscle blunt- ly in the same manner— that is, corresponding to the direction of the fibres. The centre of this cross inci- sion must be identical with the one of the oblique lon- FiG. 10. — Direction of the incision in appendectomy. gitudinal incision. It is true that there is a longitudinal as well as a crossed wound, but the size of the former, if the margins be kept well asunder, permits of con- siderable distention of the second incision, which, in emergencies, might be prolonged to the sheath of the rectus muscle on one side and to the crista ossis ilei on the other. Nothing but the fatty subserous stratum, which par- titions off the peritoneum, now remains ; it must be 62 IS APPENDICITIS A SURGICAL DISEASE? pushed out of the way. After having stopped each point of hasmorrhage thoroughly, no matter how scant it may be, the peritonaeum is lifted by a small-toothed forceps and is carefully raised at its most elevated point just wide enough to permit the insertion of a grooved di- FiG. 11. — Removal of the appendix after securing tlie base by a ligature. rector, upon which the further division of the perito- naeum is completed. Now the index finger is introduced to get hold of the appendix. Sometimes it can be made to slip out like a little eel, so that the whole operation can at once be finished extra-abdominally. But in the major- IS APPENDICITIS A SCRCxICAL DISEASE? 63 ity of cases the caput coli must first be drawn out; and even then the adhesions formed by previous inflamma- tory processes tighten it to such an extent that the abdominal wound must be enlarged transversely. But even then it frequently takes some time until the appen- dix, which has undergone pathological changes, can be brought into view. In order to get a landmark it is best to secure the ascending colon, which can be recognized by the longitudinal direction of its muscular fibres. By following the ascending colon downward the fundus of the appendix is reached anteriorly. If there be no adhe- sions of any account the appendix is removed after hav- ing ligated its mesenteriolum in three or more portions (Fig. 11). For this purpose I use the formalin catgut exclu- sively, the sterility of this material, after it is boiled, being indisputable. After squeezing the contents of the appendix into the caecum, the fundus of the appendix is tied with a catgut ligature. The same procedure is repeated about half a centimetre below (compare Fig. 11). Then with one stroke of the scissors the appendix is severed closely above the lower ligature. By previous- ly having squeezed out the contents of the appendix and by tying doubly afterward, the exit of any facal matter is prevented. The protruding mucous membrane of the appendix, after being disinfected with a strong solution of bichloride of mercury, is then seized with an artery forceps and pulled out as far as possible. Now it is cleanly cut off with the scissors (Fig. 13) . There is then left a muscular serous flap, which can easily be united by three Lembert sutures (Fig. 13). x\fter the removal of the mucous membrane some iodoform powder is dusted over the remainder of the mucous membrane in 64 IS APPENDICITIS A SURGICAL DISEASE? the depth ; but dusting the little wound margins, which are to be united, is to be very carefully avoided. All Fig. li. — Removal of the mucous membrane. these manipulations take place after the neighboring in- testines, particularly the area situated directly below the appendix, are protected extensively with sterile com- presses. In some cases the appendix is so deeply imbedded in thick adhesions that it appears, as said above, like a mummy baked into lava. Its structure is then so much changed that it can only be identified after a long search. Then it is recommendable to separate the appendix at its cascal end first, so that the colon can be pushed away from the operating field, after which removal of the appendix can be done much easier. It has happened to me repeatedly to have to proceed step by step by mak- ing very small incisions to shell out the appendix, which IS APPENDICITIS A SURGICAL DISEASE? 65 sometimes reached crosswise up to the spinal column. After its removal its groovelike bed resembled the emptied husk of a bean pod. In doubtful cases it is preferable to leave a serosa fragment rather than to extirpate too radically, in which cases the surface bleeding may become considerable. After having stopped every little bleeding point minutely, whether by means of hot compresses or with the finest formalin catgut, the peritoneal margins can be united with the same catgut. Then follows the trans- verse fossa. The transverse and the external oblique muscle require but little suturing, as they approximate themselves by themselves as soon as the tenacula are withdrawn. Hernia after this operation is an impossible sequel. It can occur only in cases where the great extent of Fig. 13. — Suturing the stump. adhesions necessitates enlarging the transverse wound to such an extent that the sheath of the rectus muscle 5 06 IS APPENDICITIS A SURGICAL DISEASE? has to be injured. It is, of course, in the interest of the patient to enlarge the opening at the expense of a possible hernia rather than to restrict the liberty of in- tra-abdominal manipulations. Still, I have always suc- ceeded so far in removing the appendix within the limits described without attacking the neighboring tissues. The technics of appendicotomy {sit venia verho) is the same in principle, be there an acutely inflamed, a perforated, or a gangrenous appendix. Virtually the preparations should be just as thorough as if there had to be done a simple appendectomy in a non-infected abdomen. The patient can not, of course, spend two days in making preparation; but the disinfecting pro- cedures immediately preceding the operation should be carried out with great strictness, while the patient is anaesthetized. From the time of the consultation up to the time of the operation at least two hours elapse, during which time there is a chance to scrub the abdomen with green soap, and alcohol thereafter. Up to the time when the ansesthesia is complete a poultice of green soap or forma- lin should be kept on the abdomen. If the pulse is of a bad quality, a subcutaneous saline infusion should always be given. I am accus- tomed to administer a saline infusion shortly before each capital operation prophylactically if the pulse is not very good. The direction of the incision is also the same. But if palpation or percussion indicates the presence of an exudate, the incision must be made as lateral as possible. Generally the line drawn from the symphysis up to the anterior end of the eleventh rib answers best. But if the exudate be situated far outward, the incision may be IS APPENDICITIS A SURGICAL DISEASE? 67 made nearer to the spina anteriora superiora ossis ilei. It may easily happen that in incising above the so-called McBurney's point the partition walls, situated toward the median line and formed of protecting adhesions, should be cut. This deplorable accident has happened twice to me. Such a focus, secluded by adhesions from the abdominal cavity, becomes, in fact, extraperitoneal, and its opening is nearly as innocent as that of an abscess situated not too superficially on most other parts of the body. The incision should not begin above the symphysis, as in simple appendectomy, but partly above it, as it is exceptional that the lower limits of the abscess can not be followed down to the true pelvis. As demonstrated above, the formation of small ab- scesses directly above Poupart's ligament, which are often only demonstrated by percussion, is by no means of rare occurrence. In the last instance one may be guided as to the preference of the direction of the in- cision by the result of the palpation or percussion. By all means the principle should be obeyed : " Better too far outward than inward." The external oblique muscle can also be separated bluntly. In regard to the fibres of the internal oblique and the transversalis, which run crosswise, it is not necessary to be as conservative in the case of the presence of an exudate as if there was a simple appendectomy to be performed. If speed is required, the fibres may be divided nearly transversely — that is, directly parallel to the skin incision. But in simple appendicitis or pyap- pendix the blunt method always holds good. After having arrived at the peritonaeum the way is best cleared, if there be an exudate, with the groove(i 68 IS APPENDICITIS A SURGICAL DISEASE? director. If pus appears on it, a small forceps is pushed along the groove of the instrument and the opening in there gradually dilated. Frequently the dark-red cae- cum, covered with fibrinous flocks, presses forward, so that the greatest care has to be observed not to injure it with a cutting instrument. Therefore it is urgently advisable to use none but dull-pointed scissors or scal- pels for the further division of the peritongeum. Now careful wiping and inspection is done. Gener- ally, only fresh adhesions are found, and in order to approach the appendix, tightly bound down, they have to be severed first by moderate pulling. During these pro- cedures the neighboring organs must always be well pro- tected by gauze mops which are pushed underneath. If the appendix is closely attached to the wall, con- sisting of protecting adhesions, it is preferable to leave it there, provided it can not be removed without destroy- ing the protecting wall. Then an iodoform gauze strip should be built around it or its fragments, which can be removed safely a few days thereafter. But if it can be shelled out without such difficulties, it should be done, and the tying and extirpation should be performed ac- cording to the methods of simple appendectomy. But every possible means should be tried before making the decision to leave an appendix, degenerated and infected, in the abdomen. It often happens that we are too conservative, and small abscesses, covered by the im- bedded appendix, are overlooked, so that the patient may still die, the large abscess only having been dis- charged and one or more little foci upholding and spreading the infection. If there is complete gangrene, the appendix can not be recognized as such any more. There its grayish-black IS APPENDICITIS A SURGICAL DISEASE? 69 fragment must be removed with a blunt forceps. Even the slightest pull on its cffical junction may cause the discharge of fffical contents, and it is therefore of the greatest importance to push gauze compresses without delay underneath the endangered area just as soon as the appendix comes into view. Suturing is inadvisable; iodoform-gauze packing is to be preferred, after having cleaned the abdominal cavity thoroughly. Sometimes small fffical fistulge form, which usually close spontane- ously. If the mucous membrane protrudes, the attempt may be made to cauterize the ectropion by Paquelin's cautery. If this proves ineffectual, extensive post-operative means have to be resorted to (compare Case VIII, Fig. 9). In gangrene, however, a protecting wall, consisting of adhesions, is hardly ever formed; in such cases we have to deal with peritonitis rather than with appendi- citis. Sometimes it fortunately happens that the adhe- sive peritonitis agglutinates the intestinal loops adjoin- ing the cascal region, so that really extensive perito- nitis is confined to a comparatively circumscribed area. This rare good fortune is explained by the careful evac- uation of pus foci by the guarded boring index finger, and furthermore by the minute wiping off of all fibrinous flocks. (In my article on Appendicitis in the Berliner Minische Wochensclirift, 1896, No. 37, 1 described a very interesting case of this sort.) After the inflammation has given up its circum- scribed character then matters are much worse. Still, even in such desperate cases, results are obtained now and then, especially if one has the luck to discover en- cysted foci after external inspection and palpation of the peritoneal cavity. By exercising a great deal of patience 70 IS APPENDICITIS A SURGICAL DISEASE? it is often astonishing how foci are discovered which were not suspected on a superficial examination. An- aesthesia should be employed in such cases. Such foci must, of course, be exposed thoroughly. The peritoneal cavity is washed with a hot saline infusion, the fibrinous flocks are wiped off carefully, and extensive drainage is effected by the use of iodoform wicks. The thorough exposure of the suspicious peritoneal region first of all permits a complete evacuation of the pus accumulations from the edges and niches of the ab- dominal cavity. Adhesions, the results of preceding in- flammatory processes, can be loosened easily, even though the thorough disinfection of the abdominal cav- ity still remains a pious desire rather than a surgical re- ality. Still, by these procedures a considerable amount of accumulated infectious material is got rid of, not to speak of the most beneficial lowering of the intra-ab- dominal pressure, and the consequent freeing of the res- piration. There is a series of authentic reports, accord- ing to which a cure was effected in most desperate cases, to the treatment of which the surgeon proceeded without a spark of hope, where, for instance, the pulse was hardly perceptible. Vice versa, however, many cases have ended fatally where the prospects seemed entirely favorable. If the gangrene has persisted for several days, the caecum will naturally particijiate, considerable loss of substance then occurring sometimes. If the area thus affected is not thoroughly exposed and the necrotic tis- sue removed, the patient will surely succumb. I found that the best route from wliich such foci are exposed is by the lumbar region, a long, transverse incision being made from the abdominal incision backward, if neces- sary to the outer margin of the lumbo-dorsalis muscle. IS APPENDICITIS A SURGICAL DISEASE? 71 Sometimes one is surprised at the extent of the necrotic process in this region, which escaped notice if inspected from the abdominal opening only. The latter should be sewed up after all necrotic fragments are removed and the wound cavity drained from the lumbar opening. In two of my most desperate cases recovery took place, although these rigorous procedures had to be undertaken while the patients were nearly conscious, respiration having stopped shortly after the ansesthetic had been ad- ministered. In both cases, one being of five and the other of seven days' standing, pus had been present in the urine. It is no doubt depressing for a surgeon to proceed to heroic manipulations under such gloomy circumstances, where he must fear every moment that the small vital spark would become extinct. And, on the other hand, he can not forget that such a patient has nothing to lose and everything to gain, and that under these cir- cumstances at all hazards this last chance should be offered to him. His permission is easily obtained, for such patients often suffer intensely, and are generally cognizant of the hopelessness of internal medication. Unfortunately, in most cases, the valuable span of time, which may eventually offer a chance for recovery, is sac- rificed to aimless deliberation. , In infection of high virulence the prognosis is abso- lutely bad. When, on incising the peritonseum a serous exudation of a fsecal odor pours forth, I always say to myself : " Lasciate ogni speranza." Up to date I have lost all my cases of this kind. This form of exuda- tion seems to point to an infection of high virulence. Treatment with antitoxine has also proved a failure in such cases. 72 IS APPENDICITIS A SURGICAL DISEASE? Eegarding the occlusion of the abdominal wall, pri- mary union should always be striven for in simple in- flammatory processes. Consequently the abdominal wall should be sewed up. In simple abscess formation the wound cavity is packed with iodoform gauze, and the abdomen is kept open and protected with a large piece of immobilizing moss board. The dressing is changed once in three days. If virulent infection is assumed, the moist open- wound treatment is substituted for the dry open treat- ment by keeping the gauze filling in the wound cavity constantly moist with formalin. Instead of the moss board and the bandaging, only a compress, saturated with the formalin solution, is put over it. If the pa- tients do well, a laxative is given twenty-four hours after the operation. As an anaesthetic, nearly always ether was employed. For the last six months Schleich's mix- tures were tried, and while I have to acknowledge the ease with which some patients came under and out of their influence, I have failed to discover any material advantages over the usual methods of ether ansesthet- ization. All patients in whom the open-wound treatment is tried have to wear an abdominal supporter, which has to be well padded on the right side. Physicians. who desire to keep au courant with the advances of medicine and surgery should read The New York Medical Journal Subscription price, per annum, $5.00 Volumes begin in JANUARY and JULY D. 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