^5^SS!SS:!i.\«:.«»>;«-.; UREs ON Appendicitis Columbia Mnibersfitp ^ "g *\ T in tfje Citp of i^eto ^orfe » ^ctiool of Bcntal anij #ral ^urgerp ^^efereuce Hihtavp Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/lecturesonappend1897morr HOW WE TREAT WOUNDS TO-DAY. ROBERT T. MORRIS, M.D. NEW EDITION REVISED. i6mO, CLOTH. PRICE $I.OO The book is so thoroughly practical that it must be commended to those who wish to acquire an exact knowledge of the details of antiseptic treat- ment. — Bost. Mid. and Surg, your.^ 1886. Mais ce rapide apergu ne peut donner qu' une idee fort insufKsante de ce precieux petit traits, et nous ne saurions trop en recommander la lecture. — Revue de Ckirurgie, Dec. 10, 1886. G. P. PUTNAM'S SOX?, Publishers, New York and London. LECTURES ON APPENDICITIS AND NOTES ON OTHER SUBJECTS BY ROBERT T. MORRIS, A.M., M.D. Fellow of the New York Academy of Medicine, American Association of Obstetricians and Gynecologists, American Medical Association ; Member of the New York State and County Medical Societies, Society . of Alumni of Bellevue Hospital, Linnean Society of Natural History, etc. SECOND EDITION, RE VISED AND ENLARGED With Illustrations by Henry Macdonald, M.D. G. P. PUTNAM'S SONS NEW YORK LONDON 27 WEST TWENTV-THIRD STREET 24 BEDFORD STREET, STKAND £^£ linichcrbodur |1rrss 1897 '/>e6 {>/ Copyright, 1S95 BY G. P. PUTNAM'S SONS Ube 1kntct!erbocf?er ipresB, IRcw IROcbellc, m, !3« -ox > PREFACE. 4i Eight years ago, when there was confusion in antiseptic methods of wound treatment, I presented a httle book, which was accepted because it told of one way for accomplishing certain ends. At the present time, while there is confusion of ideas on the subject of appendicitis, it is perhaps a favorable time for blazing one clear trail through the subject in a similar way. In the matter of operative procedures, I have due respect for methods which are different from my own, believing that in the art of surgery every surgeon is a law unto himself, and that he knows the factors of his own success. This collection of lectures includes the substance of my teaching on the subject of appendicitis at the Post-Graduate Medical School in New York, and I have added a series of notes on other subjects which have received little attention in literature, but which have interested my class. The terms local leucocytosis and phagocytosis I have used synonymously, pending further investigation. The substance of many of the notes has appeared in various periodicals — e.g., the New York Medical Journal and Nezv York Medical Record, the Annals of Surgery, the New England Medical Monthly, the Post-Gradiiate, the Transactions of the American Association of Obstetricians and Gynecologists, Transactions of the Southern Surgical and Gyneco- logical Association, Transactions of the American Medical Asso- ciation, Transactions of the International Medical Congress at Berlin, i8go. Transactions of the New York State Medical Society, Transactions of the Pan-American Medical Congress. Aid in research work was given by Dr. Arnold Eiloart and C. N. Haskell, in chemistry ; and by Drs. J. C. Smith, H. T. Brooks, and William Vissman, in pathology. Dr. J. C. Smith furnished the photo-micrographs, and the illustrations from my specimens and dissections were made by Dr. Henry Macdonald. CONTENTS. CHAPTER I. , PAGE Preparation of Surgeon and Patient ...„,. I-9 CHAPTER II. The Appendix Vermiformis Ceci ...,». 10-15 CHAPTER III. Appendicitis <, ,...,,, . 16-48 CHAPTER IV. Surgical Treatment of Appendicitis ...... 49-83 CHAPTER V. The Action of Various Solvents on Gallstones .... 84-91 The Influence of Remains of the Embryonic Vitelline Duct in the Produc- tion of Moist Navels, and of Eczematoid Inflammation about the Navel 92-93 Malignant Islands at the Navel Occurring Simultaneously with Malignant Disease of the Abdominal or Pelvic Organs A Last Resort Hernia Operation ..... The Experimental Production of Ileal Intussusception with Carbonate of Sodium ........ The Reason why Patients Recover from Tuberculosis of the Peritoneum The Prevention of Secondary Peritoneal Adhesions by Means of an Aristol Film ........ Another Method for Palpation of the Kidney . ' . ' . Experiments Germane to the Subject of Abdominal Supporters after Laj arotomy ........ An Addition to McGuire's Operation for a Supra-Pubic Urethra The Drainage Wick ....... Endoscopic Tubes for Direct Inspection of the Interior of the P>ladder and Uterus . . . . . . . . .117-119 94-97 98-99 I 00-101 102-104 105-106 107-10S 109-1 I I 112-114 11=;- 1 16 VI Contents. The Action of Trypsin, Pancreatic Extract, and Pepsin, upon Slouglis and Coagula ......... The Removal of Necrotic and Carions Bone with Hydrocliloric Acid and Pepsin ........ Is Evohition Trying to Do Away with the Clitoris? , The Mechanism and Anatomy of Subluxation of the Head of the Radius Pott's Fracture, and the Fracture of tlie Fibula which follows Adduction o the Foot ........ The Dowel-Pin in Dislocation of the Acromial End of the Clavicle . The Dowel-Pin in Fracture of the Clavicle Mallet-Finger .... Two Cases of Conservative Surgery of the Arm Skin Grafting from Blisters Phelps's Flare-Lip Operation in Two Steps . Distension of Fistulous Pipes with Plaster of Paris to Facilitate thei Removal ........ Prevention of Abortion by Removal of a Uterine Fibroid Reduction of an Inverted Uterus by Incising the Constricting Ring Intra abdominally Hysterectomy for Placenta Previa Ovarian Transplantation Healing through the Agency of Blood Clot Subsequent Notes on Appendicitis F-ormalin Catgut INDEX 123-125 1 26-1 3 1 132-135 136-13S 139-141 142 143-145 146-150 151-152 153 154 154 155 155 156-159 161 162 171 LIST OF ILLUSTRATIONS. Culture tube .... Portable set of culture tubes . The appendix vermiformis ceci Concretions .... Section of normal appendix . Section of infected appendix . Section of normal mucosa and lymphoid layer of appendix Section of appendix undergoing destruction Acute ulceration of appendix Chronic ulceration of appendix Lymph space infiltration Thrombus in mesappendix Proliferating endarteritis Round sloughs of appendix Round slough of appendix Gangrenous appendix Gangrene of mesappendix Perforated appendix Multiple perforations of appendix . Appendix living by adhesion circulation Interval cases ..... Adhesion band snaring bowel Rhexis of appendix .... Tenacula stretching skin Guy line ..... Aponeuroses involved in appendix operations Evanescent scar Embryonic remains at the navel Adeno-carcinoma of navel 6 7 lO 13 16 16 18 19 21 21 22 23 24 23 26 27 28 29 29 30 31 32 34 54 55 56, 57 . 61 92,94 95, 96 vm List of IlliLstrations. Bowel fastened at hernial opening Ileal intussusception Supra-pubic urethra Drainage wick Endoscopic tubes . Decalcified bone . Section of normal clitoris Section of adherent clitoris Orbicular ligament Dislocation of clavicle . Dislocation of clavicle reduce Fracture of clavicle Mallet-finger . Injured and repaired arms Blister graft . Transplanted ovarian tissue PAGE • 99 . 101 112, 113 . 116 • 117 124, 125 . 126 127, 12S • 132 • 139 . 140 . 142 143, 144, 145 146, 147, 148, 149, 150 .151 . 157, 158 LECTURES ON APPENDICITIS LECTURES ON APPENDICITIS CHAPTER I. PREPARATION OF SURGEON AND PATIENT. General Cleanliness is obtained by washing our hands, and the skin of the patient, at the proposed field of operation, with ordi- nary soap and water, aided by a nail-brush. Special Cleanliness for the surgeon and assistants is gained by immersing the hands in 1:2000 bichloride of mercury solution for five minutes in preparation for ordinary work. Theoretically, this -does not completely sterilize the hands, but practically it has been sufficient in my experience. It is difificult to destroy absolutely the spores of some of the bacteria, but if the whole operation is properly conducted, we need hardly fear the few spores which re- sist the action of the bichloride on our hands. After operation upon a distinctively septic case, and before proceeding to the next one, the hands are prepared by immersing them in a solution of permanganate of potassium, one drachm to the pint, until they are deeply stained, and then bleaching them in a solution of oxalic acid, two drachms to the pint, and afterward rinsing in 1:2000 bichloride of mercury solution. Special cleanliness for the skin of the patient is obtained by methods employed for cleansing the hands, but, in addition, the skin is always shaved first, and, if possible, a pad of moist bichlo- ride gauze is kept in contact with the skin at the proposed field of operation for ten hours. Special cleanliness of the alimentary canal of the patient is aimed at by emptying the bowels, and then giving five grains of salol. This is an important measure in abdominal work, because the process of digestion stops when the abdominal sympathetic nerves are shocked, and fermentation ensues, poisoning the patient with saprophytic products. Salol lessens fermentation. 2 Lectures on Appendicitis. Iiistriujicnts are sterilized by boiling for ten minutes in i:ioo bicarbonate of sodium solution. The boiling sterilizes, and the bicarbonate of sodium prevents oxidation of the bright metal and of the cutting edges. At the time of the operation, instru- ments are allowed to remain, while not in use, in boiled water. Towels are sterilized by boiling for ten minutes just before using,, if they were boiled for half an hour after use at a previous opera- tion. Sponges. — Reef sponges, costing less than two dollars a pound, are used in my work. They are soaked in warm water for a day to soften the dry sarcode which covers the spicules. After a gen- eral washing, they are placed in hydrochloric acid solution, one part to ten, and left there until all shell sand is dissolved. Ten hours will suffice for some of the sponges, but an addition of acid will be necessary if the original amount is used up on excessively abun- dant lime salts. The cleansed sponges are placed in permanganate of potassium solution, i:ioo for ten minutes, and are afterwards rinsed before going into the bleach bath of oxalic acid solution, 1:30. As soon as they are white, a few minutes' immersion being sufificient, the ones that are wanted for early use are immersed in 1:4000 bichloride of mercury solution, containing glycerine in the proportion of one ounce to the pint, and they are left in the solu- tion for ten hours. After being squeezed dry, they are placed in glass jars ready for use. Sponges that are not to be used for sev- eral months are stored dry, tied up in paper bags. A repetition of the treatment, minus the hydrochloric acid, will answer for sponges that have been used. The permanganate of potassium combines with the organic sarcode, and stains the inorganic spic- ules, acting as a germicide. The oxalic acid decomposes the potassium compounds, and is destructive to bacteria and their spores. The bichloride of mercury acts further as a germicide, and glycerine is employed because it is hygroscopic, and prevents for several weeks the change of the bichloride of mercury to calo- mel — a change which occurs rapidly when dry bichloride is ex- posed to the air in thin layers over the spicules. If a strong solution of bichloride of mercury is used, it makes the sponges too hard. Gauze. — Absorbent gauze, which constitutes the principal bulky dressing, is prepared by boiling cheesecloth or mull in a solution of carbonate of sodium (washing soda) i:i6, for two hours: chan- ging the water, rinsing, and boiling again in the same solution for Preparation of Sztrgeo7i and Patient. 3 two hours, then rinsing and boiling in pure water for ten minutes. The gauze is then absorbent, because the soda has saponified the fat and broken up the gummy elements of the cotton fibre. The gauze is finally washed in clean boiling water, and immersed in 1 :2000 bichloride of mercury solution, containing one ounce of gly- cerine to the pint. After squeezing dry, the proportion of the lot that is likely to be used in less than two months is stored in glass jars, but the remainder, as with the sponges, should be securely tied up in paper bags, and again immersed in bichloride and gly- cerine before being placed in the jars for early employment. Iodofo7'vi Gauze \% not used in my clinic for wound treatment, be- cause the iodoform and the fixing agents interfere with the capil- larity of the gauze, and thereby destroy the nice mechanical action which is the chief and great virtue of gauze dressings. Absorbent Cotton can be prepared from cotton batting by the process employed for gauze, and it makes a much cheaper dress- ing, but the absorbent cotton does not look attractive unless it is re-carded after treatment, and on that account is not often manu- factured by the surgeon at home. If the absorbent gauze and cotton are purchased from dealers, each lot must be tested sepa- rately, because a patient's life is often staked absolutely upon the capillarity of a filament of gauze, and I have bought alleged ab- sorbent dressings which would have betrayed the patient's trust in me. Test absorbent gauze and cotton by dipping one end of the filament of prepared and unprepared stuff, side by side into a glass of warm water. The water will be seen to shoot up into the absorbent stuff instantly. Drainage Apparatus. — Drainage is not often required for aseptic wounds, but it has a place of vital importance at times. I depend almost entirely upon the drainage wick, made by rolling absorb- ent gauze in gutta-percha tissue, very much as one rolls tobacco in a cigarette paper. The average wick is about the diameter of a cigarette, but longer. (See article on Drainage Wick.) Sutures and Ligatures. — Silk is used by me in one place only in surgery, and that is for ligating the inner tube of the appendix. The tiniest of buried knots is desirable at that point, and the finest strand of silk answers the purpose well. The silk is boiled for half an hour, and then stored on a glass rod in a glass tube filled with alcohol. Catgut. — Catgut is the ideal material for sutures and ligatures, if prepared according to the following directions: Every surgeon 4 Lect2ircs on Appendicitis. must attend personally to the preparation of his catgut. No matter how good the intention of the dealer, the work is some- times given to workmen who do not know what responsibility they are to share with the surgeon, and the patient's needle may turn on a pivotal suture. I buy from L. H. Keller & Co., 64 Nassau Street, New York, the hanks of raw catgut in the form known as "bow-lines." Each bow-line is one metre in length, and the form is convenient because a few strands can be removed from the storage bottle and placed in a saucer of alcohol at the time of the operation, thus avoiding the danger of contaminating the mass remaining in the storage bottle. Different dealers num- ber their sizes of catgut arbitrarily, and in order to establish a standard I have proposed that the American Standard Wire Gauge be used. Such a gauge can be found in almost any me- chanic's shop, and there is no good reason why catgut should not be measured by this standard. The sizes that are employed for almost all of my work are No. 25 and No. 20, American wire gauge. The hanks of raw catgut are placed in a glass jar and freely covered with commercial sulphuric ether, in which they remain for a week. The ether removes the fixed oil, and acts as a germicide, becoming very foul, however, and unfit for further use. The foul ether is poured off at the end of a week, and fresh ether containing bichloride of mercury, in the proportion of I 14000, is added. After standing in this new ether for a week, the hanks are transferred to a storage bottle of absolute alcohol, containing bichloride I ".4000, and are ready for use, unless the chromicizing process is preferred. I use cliromic gut altogether, because smaller sizes of this will take the place of clumsy strands of simply prepared gut. To chromicize the catgut, it is first pre- pared by the simple process, and is then placed in a solution of bichromate of potassium and alcohol, fifteen grains to the pint, first dissolving the bichromate in one ounce of distilled or boiled water, and adding it to the alcohol in the form of a watery solu- tion. The catgut remains in the solution of bichromate of potas- sium and alcohol for fifteen hours, and is then drained, and placed in absolute alcohol for storage. The chromicizing process doubles the resistance to absorption of the catgut in the tissues. When first prepared, the resistance is not quite doubled, and after stand- ing in the alcohol for a year, it is rather more than doubled ; but this variation is of little practical importance. Catgut left in the bichromate of potassium solution for more than fifteen hours be- Preparation of Surgeon and Patient. 5 comes too resistant, and may not be absorbed in months. Pre- pared for fifteen hours in the fifteen-grain-to-thc-pint solution, No. 25 is absorbed in about ten days, and No. 20 in about twenty days. At the time of the operation, a sufficient number of bow- lines are removed from the storage bottle, and placed in a saucer of alcohol ready for immediate use. Any bow-lines left over after the operation are thrown away. After preparing a lot of catgut, it is tested by cutting up a strand, placing the pieces in boiled distilled water for ten minutes, and then planting the pieces in a test tube of agar-agar. Irrigating Solutions. — The only irrigating solutions that I em- ploy are physiological saline solution and strong hydrogen dioxide. Hydrogen Dioxide is used in full strength for flushing septic cavities at the time of the operation, and is then washed out with the physiological saline solution. The dioxide of hydrogen is a powerful germicide, and it not only destroys the bacteria, but throws up pus and septic fluids in a foamy mixture, which is easily washed away. The same antiseptic is used in many septic cavities after operation until granulation begins, but we must dis- continue its use then, as a rule, because the peroxide follows leu- cocytes into granulation tissue, and thus delays repair. Physiological Saline Solution, representing the normal propor- tion of chloride of sodium in the blood, is the least irritating and the most useful general irrigating solution. It is made by boiling ninety grains of chloride of sodium in one quart of water. Common Boiled Water irritates the tissues, and is somewhat corrosive, as may be observed by dropping it on the eye, or placing a glistening piece of peritoneum in it for an hour. Water in the eye causes smarting, and it dulls the surface of the peri- toneum. In a peritoneal operation it injures the serosa slightly, and may cause vexatious little adhesions afterward. The injury to the serosa may besufUcient to close the mouths of the lymphatics upon which the surgeon depends for very important aid in carry- ing off septic matter. Therefore unsalted water should not be used for irrigating purposes. Chem.ieal Antiseptic Solutions are still more irritating than plain water. We depended upon them until progress carried us to aseptic surgery. Physiological saline solution is used for all ordi- nary purposes of irrigation in surgical work, and it is practically unirritating. The sponges are kept in basins of it at an operation, Led tires on Appendicitis. and the surgeon's hands are washed in it for neatness' sake while he is at work. Aristol. — Aristol is similar to iodoform in its action, but it is preferable to iodoform because it adheres to tissues much more tenaciously; because it seldom, if ever, produces any toxic efTects, and because it smells better. Aristol is not directly an antiseptic, but it quickly forms with lymph a thin protect- ing coagulum which is almost impenetrable to bacteria. The free iodine which is given off, destroys irritating ptomaines, and allows leuco- cytes to marshal their forces on one side of the coagulum wall, while bacteria are making slow progress from the other side. Aristol is of the utmost importance in closing tissue planes against infiltration from a wound. For instance, after supra-pubic cystotomy, it will make a fine impenetrable wall about the drainage track. It will do the same thing after the removal of the gangrenous appendix, or a pus tube, and it makes very simple the question of drainage after operations upon the gall-bladder and bile ducts. The comfort that I find in the use of aristol according to a proper technique is very decided. The drug must be studied with reference to its use in forming a thin protecting coagulum. Aristol is apparently not absorbed readily in the tissues, but it becomes harmlessly encapsulated. In rabbits upon which 1 experi- mented, and in operations upon patients in whom I had previously employed it for prevent- ing secondary peritoneal adhesions, the aristol was found encapsulated in little spots, retaining its color, and producing an appearance which will puzzle pathologists who come across it without knowing that aristol has been used in the case. Aprons. — A very thin and light apron of rubber dam with rub- ber tube strings, is made for me by John Reynders & Co., of New York. These aprons can be packed in very small space, and they are boiled and otherwise cleansed with ease. One of the aprons rolled over a rope, and leaving half of the apron free, can be tied about the waist of a patient in Trendelenburg's posture. Used in this way it keeps the clothing of the patient dry, and conducts fluids into a proper receptacle. Fig. I. Culture Tube. A, cotton plug. B, swab carrier. C, swab. D, agar-agar. Preparation of Surgeon and Patient. 7 CulUirc Tubes.— Yowx or five culture tubes of agar-agar arc car- ried in a little case in my instrument bag. A swab fastened to a copper wire rests in the tube, not quite touching the culture medium. The mouth of the tube is filled with scorched cotton. At an operation in which it is interesting to note what species of Fig. 2.— rortable set of culture tubes for the surgeon's bag. bacteria have been at work, the swab is touched against the in- fected tissues, and then carried to the agar-agar. The swab^ is then thrown away, and the mouth of the tube again plugged with scorched cotton, after which the tubes are handed to the bacteri- ologist for further investigation. 8 Lectures on Appetidicitis. Results. — The efficiency of the comparatively simple resources above described is shown very well in one of the hospitals at which I have none of the complete advantages which are furnished at our. Post-Graduate Hospital, and in other hospitals in New York, where my patients receive elaborate preparatory treatment and detailed after-treatment under my personal supervision. I refer to the Ithaca City Hospital, which is a transformed woodert dwelling-house, having meagre advantages as a hospital. Almost none of my patients there received any preliminary treatment^ but were prepared on the day of the operation, and frequently on the operating-table only. I saw most of these patients for the first time then, and not again afterward. The medical staff con- sists of a large number of physicians and surgeons, and yet during- a period of two years there has been but one death among the surgical cases at that hospital in the service of any of the oper- ators. That death occurred after a hip-joint amputation in one of my patients who had suffered for years with suppuration from the whole length of the femur, following osteo-myelitis, and who had amyloid kidneys and puffy feet on the day of operation. I am at liberty to give my own statistics only. From the hospital years February 6, 1893, to February 6, 1895, I operated upon the fol- lowing 193 cases, in 178 patients, at the Ithaca Hospital. No' patients were refused operation excepting hopeless cases of carci- noma and sarcoma, and exploratory operations were done in five cases of this sort to determine if an involved organ, such as the gall-bladder or intestine could possibly be operated upon with a prospect of benefit to the patient. Acute appendicitis ; perforation of cecum ; abdomen distended with pus and gas, not encapsulated r Acute appendicitis ; perforation opening into abscess cavities, encysted 4 Acute appendicitis ; mucosa desquamating I Chronic appendicitis ; various adhesions and complications ir Typhlitis, perforative ; abdomen full of sero-pus i Abdominal hysterectomy for very large myomata and fibromata 6 Abdominal hysterectomy for a placental hemorrhage i Vaginal hysterectomy for cancer, i ; procidentia, i ; chronic metritis, 3 5 Abdominal hystero-pexy for retroversion of uterus 5 Abdominal hystero-pexy and removal of destroyed adnexa 6 Removal of large ovarian cysts 6 Celiotomy for conservative treatment of adherent or diseased adnexa of the uterus, non-suppurative 7 Celiotomy for removal of pyogenic oviducts 2 Exploratory celiotomy to determine if malignant growths could be operated upon. 5 Gastrorrhaphy for chronic dilatation of stomach r Bassini's operation for hernia 2, Preparation of Surgeon and Patient. 9 Macewen's operation for hernia i Closure of ventral hernial opening 2 Supra-pubic cystotomy, stone, i ; tuberculosis, i ; 2 Nephrorrhaphy for loose kidney 3 Removal of navel for eczema I Removal of breast and axillary glands for cancer 11 Repair of rupture of perineum. •. 7 Repair of perineum and cervix simultaneously 3 Repair of cervix .... 2 Removal of decomposed fetus 5 months (vaginal route) i Von Bergmann's hydrocele operation (excision of sac) 4 Lister's varicocele operation (excision of veins) 14 Ligature of dorsal vein of penis for impotence 2 Excision of varicose veins of leg i Circumcision for phimosis 6 Amputation of penis for cancer i Internal urethrotomy for stricture 9 Removal of sphacelus of bone, tibia, 2 ; femur, i ; maxilla i 4 Amputation of forearm i Re-amputation of leg i Hip-joint amputation (death immediately, shock) I Amputation of thumb for sarcoma i Suture of fractured ulna I Tenotomy for talipes 2 Excision of tuberculous tendon of biceps brachialis i Suture of cut tendons of hand or wrist 3 Suture of dislocated acromial end of clavicle i Ligation of hemorrhoids 4 Obliteration of fistula in ano 5 Coccygectomy for coccygodynia 2 Removal of sarcomatous neuromata, ulnar, 2 ; circumflex, i ; peroneal, i 4 Removal of melano-sarcoma of brachial region i Mastoid bone opened for evacuation of abscess ; i Incision for periostitis of tibia i Extirpation of tuberculous inguinal bubo i Extirpation of tuberculous mass of cervical glands 3 Extirpation of coccygeal dermoid cyst 2 Extirpation of vulvar fistulous tract for embedded hair-pin i Extirpation of hypertrophied tonsils, child, i ; adult, i i Plastic operation after removal of cancer, lip, 3 ; cheek, 2 5 Poncet's operation for goitre i Removal of cancerous glands of neck 2 Removal of branchial cyst of neck i Removal of large fibroid tumor of neck I Plastic operation on anus, incontinence stricture 3 Fracture and replacement of deviated nasal septa 2 Removal of extensive papilloma of anal region and buttocks i Whole number patients, 178 ; Operations, 193 ; Deaths, i-. The reduction of a general surgical death-rate to a fraction of one per cent, under such circumstances is due to the resources of to-day rather than to any particular skill on my part. CHAPTER II. THE APPENDIX VERMIFORMIS CECI. The lengthened cecum of mammals has degenerated to a vermiform appendix in some species. The cecal appendage is vermiform in man and in all of the man-like apes — gorilla, orang, chimpanzee, and gibbon (several species). It is also vermiform in certain lemurs, and perhaps in some of the monkeys. Curiously enough the marsupial wombat has a vermiform appendix. In Fig. 3. — Normal appendix vermiformis ceci {^Homo sapiens) showing mesappendix and solitary artery. man, the cecal appendage is apparently a rudimentary structure which once formed an important part of the alimentary tract in the days when we needed a wisdom tooth for crushing palms and ferns, and a large absorbing surface for extracting their scanty The Appendix Vei'iniformis Ceci. 1 1 nutriment. Now, as degenerate structures, the cecal appendix, and the wisdom tooth, with its insufficient calcification, perish easily when attacked by bacteria. The microscope does not show the comparative vital energy of different cells or structures, but it is fair to assume that the unused appendix has low vitality, because we know analogously that other unused normal struc- tures lose to a certain extent their resistance to infection by bacteria. The appendix vermiformis in man was recognized as a struc- ture in the sixteenth century, and was described in the eighteenth century. It appears at about the tenth week of fetal life. As compared with the length of the colon, it is largest at birth, and smallest after seventy years of age. It is one of the structures which flutters before going out in the descent of man, and is conse- quently of extremely variable dimensions. The length of an average appendix vermiformis in a young adult is not far from three and three-quarter inches, with a diameter of the quill of the primary feather from the wing of a Canada goose. We occa- sionally find a normal appendix two inches long, or eight inches long, and I have removed several which were about half a foot long. Measurements taken post mortcni will give too great an average length, because the appendix becomes lax and elongated after the period of rigor mortis has passed. Measurements taken from specimens removed at operation will give too short an average length, because the structure contracts almost immediately on separation from the cecum, unless it is gangrenous or tense with exudates. We must therefore make our estimates from normal appendices observed while we are engaged in other abdominal work. The position of the appendix is usually behind the cecum, and pointing toward the spleen, but its tip may touch almost all boundaries of the peritoneal cavity. It is ordinarily supplied with a mesappendix, which is given off from the left layer of the mesentery of the ileum. There is good authority for the state- ment that the appendix is sometimes extra-peritoneal, but in all observations by myself, in which structures were not too badly damaged for accurate determination of that point, the appendix possessed a mesappendix. This is a matter of little practical im- portance to the surgeon, because an appendix situated behind the peritoneum could be easily released by a slit through the peri- toneum at that point. 1 2 Lectures on Appendicitis. A transverse section of the appendix shows it to consist of the structures which belong to the cecum, but with an excess of lymplioid tissue, amounting in some cases to half of the entire mass. From without inward, the layers are : peritoneum, external non-striated circular muscle, internal non-striated longitudinal muscle, lymphoid tissue, and mucosa. This does not include the connective-tissue layers, the most important of which, lying between the lymphoid tissue and the longitudinal muscle, becomes so greatly distended with serum as to form a strong factor in exudate strangulation of the lymphoid layer in some infected appendices; The principal arterial supply of the appendix is from a branch of the ileo-colic artery, which passes along the free margin of the mesappendix. This artery may be described as the solitary terminal artery of the appendix, and its anatomical arrangement is a matter of great clinical importance. In some women the appendix receives a little collateral circulation by way of the ap- pendiculo-ovarian ligament. The lymphatics of the appendix pass largely to a ganglion at the cecal extremity. The nerves of the appendix are from the superior mesenteric plexus of the sympathetic system, which is widely distributed to the small intestine, and this explains the reason why patients often suffer from colic and general abdominal pain, or pain at the navel, without realizing that its origin is at a little part of the whole, at the appendix (Fowler). It is almost an exception for the pain to be localized at the vicinity of the appendix at the outset of an attack of appendicitis. The contents of the appendix usually consist of mucus with more or less fecal matter. Under ordinary circumstances semi- solid fecal matter and gas find easy entrance to and exit from an appendix with a large lumen, as the appendix has abundant muscular ability to empty itself, and it has at the cecum a good fixed point for muscular action. It is not an uncommon sight when we are employed in abdominal work to see an appendix empty itself of distending contents when it is stimulated to contraction by the touch of the surgeon's finger. Although an average appendix can empty itself when in a normal condition, a very little hyperplasia or swelling of the lymphoid coat will suffice to lock in the contents of the lumen, and there are very many normal appendices containing concretions which cannot escape because the lumen is too small. The Appendix Vermifoinnis Ceci. 13 Appendix concretions are of three j^rincipal sorts — fecal, phos- phatic, and fatty. Fecal concretions are formed in ncjrmal appendices by the action of the muscularis rolling a bit of fecal matter into a ball or rod, which is cemented with mucus. Insolu- ble salts are precipitated out of the fermenting mucus, and as stagnant mucus is very apt to undergo decomposition, the fecal concretions are usually arranged in layers, alternately or Fig. 4. — Phosphatic appendix concretions. One bisected, showing concentric layers. homogeneously, with calcium salts. Phosphatic concretions are formed in normal appendices, and in chronically infected ap- pendices as a result of decomposition of mucus. Phosphate of calcium is the common, and sometimes the only ingredient of a concretion which may become as large as a hickory-nut. Examina- tion of three typical phosphatic concretions from three chronically infected appendices gave the following results : (i) Patient had repeated slight attacks of appendicitis ; con- cretion about as large as a No. T shot ; color, brown ; external layer and internal portion of neutral calcium phosphate, with traces of organic matter and potassium ; no magnesium or oxalic acid. (2) Patient had repeated attacks of appendicitis, some of the attacks violent. Concretion was of the size and appearance of a date seed ; grayish-brown in color ; external layer as in specimen No. I ; internal portion contained more organic matter. (3) Patient had repeated violent attacks ; concretion size of robin's egg ; of a whitish-clay color ; external layer and internal portion composed of fifty per cent, of fat ; the remaining fifty per cent, consisted of alkaline calcium phosphate. I was at a loss to account for the large proportion of fat in this and in other similar calculi, but it seemed possible that fatty metamorphosis of lymphoid cells in a chronically ulcerating ap- pendix might furnish enough fat to make a concretion, and the following analyses were accordingly made, the inner tubes com- 14 Lcctur'cs oil Appendicitis. posed of mucosa and submucosa from three sets of appendices being used : (i) Four normal appendices. Inner tubes dried at ioo° ('., weit^hed 1. 0095 gm. And yielded fat weighing 0.0860 " Percentage of fat S. 52 (2) Three appendices with small ulcerating areas. Inner tubes dried at 100° C, weighed 0.7276 gm. And yielded fat weighing o. 1410 " Percentage of fat 19-38 (3) Three appendices ivitli extensive chronic ulceration. Internal coats dried at 100° C, weighed 0.6580 gm. And yielded fat weighing o. 1 701 " Percentage of fat 25.S5 The inner tubes of the normal appendices weighed dry 9.2 per cent, more than those of the ulcerating appendices, but contained only about one third as much fat. Several observers have reported the finding of gallstones in appendices, but these specimens were probably appendix stones. Even though the composition of the concretions was largely cholesterin, it is a tenable belief that they were formed in chronic- ally ulcerating appendices. There is a theory extant to the effect that gallstones are formed in the gall-bladder by the pre- cipitation of their constituents by colon bacilli, the bacteria which are constantly present in ulcerating appendices. Appendix concretions are round, oval, flat, or rod-shaped. Some of them occur singly, and some of them in such numbers as to make the appendix look like a rosary. Various kinds of seeds are closely simulated by these concretions, and this accounts for the popular error that seeds are apt to get caught in the appendix. The deception is all the more complete when the appendix mucus becomes condensed, and rolled into yellowish prolongations from the concretions, giving almost exactly the appearance of a sprout from a seed. I have not as yet found a seed in any of the appen- dices from my series of cases, the nearest approach to one being a small piece of apple core encrusted with phosphates. The formation of fecal and phosphatic concretions, while more apt to The Appendix Verniiforniis Ceci. 1 5 occur perhaps in patients whose intestinal contents ferment, may be independent of any disease of the appendix ; but fatty con- cretions probably occur only as a result of long ulceration of the lymphoid coat. Bacteria are by all means the most important things found in the appendix. The colon bacilli which have their normal habitat in the colon are almost invariably present in the lumen of the appendix, and they are harmless dwellers there unless an infec- tion atrium gives them an opportunity to migrate into the tissues. The pyogenic streptococci are also pretty constant dwellers in the normal appendix. Many of the less important pyogenic bacteria and saprophytes, or bacteria of fermentation, harmlessly lurk in the nook of the appendix awaiting the advent of conditions which will be favorable for their rapid multiplication. When an infec- tion atrium is made, the infection is at first mixed in character, as observed in a number of my specimens of infected appendices which were removed in the very early stages of appendicitis. The streptococci are apt to outstrip other bacteria in the second part of the race, and the colon bacilli are apt to lead finally. Thriving colonies of bacteria are daily swept along through the normal colon, and are moved out of most appendices ; but we must always look at the appendix as a test tube full of culture media, and forming a nook in which bacteria lurk dangerously when once the protecting structures of the appendix have been disabled. Some of the higher entozoa are frequently found in the appendix, and the nematode oxyuris is fond of making it a nest. CHAPTER III. APPENDICITIS. According to my observations to date, appendicitis is an infective, exudative inflammation of the appendix vermiformis ceci, originating in any local cause for the production of an infec- tion atrium in the tissues of the appendix, and progressing by bacterial invasion into the layers of connective tissue, and the layer of lymphoid tissue, all of which are partially or completely disabled by interstitial exudate compression within the narrow Fig. 5. — Section of air-distended normal appendix. Fig. 6. — Section of infected appendix which was becoming disabled from interstitial exudate compression. muscular and peritoneal sheath of the appendix. The principal cause for appendicitis is mixed bacterial infection from the lumen of the appendix. The chief cause for bacterial infection from the lumen of the appendix is the formation of an infection atrium in the mucosa of the appendix by force applied in any way. I formerly surmised that the appendix was sometimes injured by pressure between a full cecum and the hard pelvic wall, supposing that the cecum was often filled with fecal matter ; but after exten- sive opportunities for observation, I have not as yet seen fecal 16 Appendicitis. 1 7 matter in the cecum at any operation, and tliere is doubt if so- called impaction is not often lymph exudate instead. Excepting in elderly people I believe that injury to the mucosa occurs most often from accidental twisting of the appendix upon part of its long axis. An infection atrium is also commonly produced by erosion of the mucosa at the site of a concretion, or by entozoa. Bacterial infection may extend into the tissues of the appendix from an infected cecum, as in typhoid fever or dysentery. An infection atrium is formed in its peritoneal outer wall at times by destruction of serosa consequent upon peritonitis extending from adherent infected oviducts or other near-by structures. The principal structures involved in appendicitis may be grouped as follows: (i) a soft, distensible inner tube of mucosa and lymphoid tissue within a confining outer tube of muscle and peritoneum ; (2) lymphatics leading to the lymphatics of the colon and mesentery ; (3) veins leading to the superior mesenteric vein ; (4) a solitary terminal artery; (5) connective-tissue planes ; and (6) nerves belonging to the mesenteric plexus. The above definition and brief statement of the salient points needs some repetition and elaboration. The mechanical feature of interstitial serum pressure appears as soon as bacteria have entered an infection atrium — the term applied to any gateway which gives entrance for bacteria to the tissues. The toxines which are the products of bacterial growth are irritating, and as a result of their invasion, serum is exuded into the tissues of the appendix, placing such tissues under the influence of serum com- pression. The lymphoid coat of the appendix and its connective- tissue cushion, forming the principal part of the inner tube of the appendix, are so much like the faucial tonsil, that I shall take the liberty of speaking of the one as the tubular tonsil, and of the other as the flat tonsil, for purposes of illustration. The flat ton- sil and its connective-tissue cushion can swell enormously because there is a whole pharynx to give room to them. Even then the flat tonsil sometimes fills the throat and its connective-tissue cushion sloughs. The infected tubular tonsil and its connective- tissue cushion try to swell just as the flat tonsil does, but they are promptly subjected to pressure within the narrow confines of the muscular and peritoneal tube of the appendix. The imprisoned tube is then further compressed by contraction of the muscular coat upon tlie inner tube, in tonic spasm, as a result of toxic stimulation of the branches of Auerbach's plexus. Over-stimula- 1 8 Lccttircs oil Appendicitis. tion of these branches leads to tonic contraction of the muscu- laris at the appendix. Stimulation extending to the branches of Auerbach's plexus at other parts of the intestine leads to irregular spasm, giving the symptom known as colic, and if over-stimulation of the sympathetic system extends still farther, the vaso-motors cause the heart to contract rapidly in partial spasm, and the heart muscle being unable to relax completely, muscular spasm of the arterioles being also present, the result is a small, rapid pulse. The tonic spasm of the outer tube upon the inner tube of the appendix is very much like putting a tight thimble upon a finger which is already tense from a felon, with serum exudate under the perios- teum. The inner tube of the appendix is composed of the same Fig. 7. — Section of normal mucosa and lymphoid layer of appendix x 600. structures as the inner tube of the cecum, but in the cecum there is abundance of room, and the lymphoid coat continues its func- tion as a strainer for bacteria, even when tense with interstitial exudates. The inner tube of the appendix, on the other hand^ anemic from compression, cannot strain out bacteria well, and its cells readily undergo toxic destruction from bacteria. The in- fected appendix with its lymph and blood circulation obstructed, is not reached in men by a collateral circulation which can bring Appendicitis. 1 9 poly-nuclear leucocytes to throw out nuclcin, and c,n'vc protection, and consequently the bacteria are free to carry r)n destructive processes. In some ulcerating appendices the inner tube may not be swollen enough to fill the lumen of the appendix, excepting when irritation of the muscular sheath excites tonic muscular spasm of that sheath, and then compression anemia again dis- ables the inner tube. Although short or long periods of muscular spasm are of regular occurrence in infected appendices, we do not '2 Fig. 8. — Section corresponding to Fig. 7, but undergoing acute toxic destruction. 1. Free border once occupied by mucosa. 2. Necrotic area. 3. Broken-down mucous follicles. 4. Breaking-down lymphoid tissue x 600. need that phenomenon for the production of compression anemia in a swollen ring of lymphoid tissue, as we are all familiar with the mechanical parallel in which a swelling barrel strains against the hoops — an exaggerated illustration, but one in which the principle is the same. The attacking bacteria which are. causing interstitial exudation in the appendix, with their toxines, may be called early to a halt by the processes adopted by nature for stop- ping the progress of bacteria elsewhere. Thus, when poly-nuclear 20 Lectures 07i Appendices. leucocytes can be carried freely to the place of infection, they pour out nuclein in large quantities, and it is very difficult for bacteria to pass the nuclein wall. The bacteria, confined within a small territory, then commit suicide with their own tox- ines, just as saccharomyces commit suicide with their own alcohol in vinous fermentation. So complete is this destruction of bacteria that an appendix lumen closed against further entrance of bacteria from the cecum may sometimes become distended with sterile serum or mucus. The appendix, however, is particu- larly unfitted to receive help, because when its single-artery circu- lation is blocked by interstitial exudates the appendix stands out as an infected peninsula, cut off from the source of protection from leucocytes, and the bacteria are at liberty to continue with their work without receiving that opposition which would meet them through a collateral circulation if the infection were in the colon. A sufficient degree of exudation compression having cut off the access of leucocytes, the toxine destruction of the inner tube of the appendix progresses to various degrees. In milder cases there is simply desquamation of patches of mucosa, but the injury is not easily repaired, and the bacteria lurking in such a disabled appendix keep up a certain degree of malign influence, sometimes for many years, though the patient be unaware of the fact. Bacteria in the lumen of the appendix are ready to make new incursions at any favorable moment, so that the appendix which has been disabled at one attack of appendicitis may be fairly said to be chronically infected afterward, because when the bacteria are not actually in the tissues of such an appendix during the interval between attacks, they are in contact with an exposed lymphoid tube, and their toxines are particularly apt to maintain a constant influence when the very common scar constrictions of the lumen of the appendix lock in septic mucus. Acute mixed infection will cause all of the acute destructive processes which occur in the appendix, and it is not necessary to look for any specific microbe for appendicitis. I have obtained cultures of bacteria from appendices removed in different stages of progress of the disease, and although the colon bacillus was always present, the infection was regularly mixed in character at first, and in some cases up to the last point of destruction of tis- sues. As previously stated, however, there is a very decided ten- dency on the part of the streptococci and colon bacilli to outstrip all others, and finally to enter into a race with each other, the Appendicitis. 21 colon bacilli usually gaining the mastery. That is why appar- ently pure cultures of colon bacilli are often found in the large abscesses, and in the fluid of peritonitis in far advanced cases of appendicitis, giving to such collections of fluid their disgusting fecal odor, which is really the odor of products of colon bacilli. The ordi- nary odor of feces is due to the harmless growth of colon bacilli in the bowel, and it was form- erly supposed that the odor of appendicitis ab- scesses was due simply to their close contact with the bowel. It was apparent, however, that the odor of a small ap- pendicitis abscess was sometimes out of all pro- portion to its size, and it Avas found that ovi- duct abscesses bearing the same relation to the bowel, and not contain- fig. io.— Chronic ul- ing cultures of colon ceration of inner tube, bacilli, were free from ^'"°™ '''^ ^"^^^'^^^ ^^^^ Tv/r- J u of appendicitis, fecal odor. Mixed bac- teria and nearly pure cultures of streptococci are destructive locally, but wide infection seems to be Fig. 9.— Destruction of inner done principally by the flagellated, far- tube of appendix at two traveling colon bacilli, which may appear points by acute ulceration. .... , , . , \\\ the liver or lung during an attack of appendicitis. The colon bacilli when once aroused seem like a swarm of angry bees about an over-turned hive, ready to attack anything in sight. It would be unwarrantable with our present knowledge to ascribe to the lowly bacteria anything so high as nocturnal habits, and yet it is certain 2 2 Lectures on Appendicitis. that a disproportionate number of the attacks of appendicitis among my cases came on between the hours of one and five o'clock in the morning. The temperature of appendicitis is interesting because of its lack of importance. Though failing to indicate the extent of infection, it gives a clue, I think, to the character of the infection. Thus, the high temperatures in appendicitis more often occur when infection is mixed, or when caused by streptococci. A tempera- ture of 103° F., or more, at the outset of an attack of appendicitis seems to mean that the toxines of mixed bacteria are sending the temperature up. When streptococci become ascendant, the tem- FiG. II. — Section of muscular coat of appendix, showing infiltration of leucocytes in lymph spaces. perature may go to 105° F., but as soon as the colon bacilli con- trol the field, the temperature of the patient may be expected to drop, and to fluctuate within a range of one degree on either side of 100° F., Avhile the disease is in progress, and no matter how widespread the infection. The temperature in appendicitis is not often elevated after the lapse of a few hours, and a colon bacillus temperature may be normal or subnormal from the outset, and so Appendicitis. 23 continue while the most disastrous effects are being produced by the bacteria in the tissues. While the toxines of the colon bacil- lus apparently do not send the patient's temperature up, they nevertheless pull the vital signs apart most insidiously, and it is not uncommon in cases of appendicitis with pure cultures of colon bacilli, to find a temperature averaging 99° F., and the pulse rate averaging 120 beats per minute for several days in succession. We must not look to the temperature then in trying to judge of the severity of an attack of appendicitis. But the pulse becomes important when it indicates the degree of intoxication of the sympathetic nervous system. Complete destruction of the Fig. 12. — Longitudinal section of vein in mesappendix, showing thrombus surrounded by leucocytes. walled-in appendix, however, may take place without producing much change in the character of the pulse, so that neither pulse nor temperature in appendicitis gives an indication of the extent of the destruction of the appendix proper. The lymph spaces of the lymphoid coat, together with the lymphatic vessels of the appendix and mesappendix, are often completely blocked with exudates and infiltrates a few hours after infection has com- 24 Lectures on Appendicitis. menced. Blocking of the lymphatic spaces interferes quickly with the lymph circulation. Infective lymphatitis frequently ex- tends from the lymph channels of the appendix to those of the colon and mesentery. The veins of the appendix are variously thrombosed by the infection, and the process may go on to ex- tensive mesenteric thrombo-phlebitis, pyle-phlebitis, portal embol- ism, and abscess of the liver. Abscess of the liver from septic appendix emboli may be looked for in almost any stage of appen- dicitis. The earliest case that has come under my notice occurred on the fifth day. There is no doubt that hepatic abscess appears in some cases of appendicitis that are too mild to attract the at- tention of the physician directly to their original character, as I have found thrombi ready to become emboli in the mesappendices of such cases. Fig. 13. — Proliferating endarteritis of solitary artery of appendix. Arterial complications give rise to some of the most striking phenomena of appendicitis. When the solitary terminal artery of the appendix becomes the seat of proliferating endarteritis, round sloughs form at the ends of the arterial twigs that are first obliterated, or the whole appendix sloughs from deficient blood Appendicitis. 25 supply. In some cases in which endarteritis causes obstruction, but not occlusion, slow ulceration occurs opposite the most affected branches of the artery. The com- plication of proliferating endarte- ritis I first described in September, 1893, but had previously examined several examples of it, finding that the tunica intima had undergone rapid proliferation as the result of acute infection. The solitary ar- tery of the appendix is obstructed sometimes in accidental disloca- tion of the appendix. The ex- pression, " dislocation of the ap- pendix," is almost an unsafe one to use, because the appendix may occupy such a variety of positions in relation to the cecum ; but when any one appen- dix which belongs behind the cecum is thrown out from behind the cecum by a sudden blow or by an unusual muscular effort, and when it cannot return to a position for which its mesappendix was adapted, that particular appendix may be spoken of as a dislocated one, and it may remain so strongly twisted upon itself, including the ; mesappendix, that arterial and venous circulation is interfered with. This, I think, is the origin of a cer- tain proportion of cases of appendicitis. The connective-tissue planes of the ap- pendix conduct infection to neighboring loose connective tissues, and very exten- sive sub-peritoneal abscesses may form, sometimes at such a distance from the appendix as to mislead the surgeon be- cause of their simulating peri-hepatitis or peri-nephritis, or psoas Fig. 14. — Two round sloughs. 26 Lccitircs on Appe7idicitis. abscess. In two of my cases, phlebitis of the veins of the left leg occurred as a result of infection travelling from the appendix across the pelvis by way of the sub-peritoneal connective tissues. In another case, an abscess formed along the left pelvic brim. The nerves of the appendix are acutely inflamed in progressing in- fection, but the most interesting nerve complications occur after the attack of appendicitis has subsided. Nerve filaments caught in contract- ing scar tissue are the source of per- sistent discomfort for the patient, but the principal symptoms appear to be due to chronic sclerosis following acute neuritis. The interstitial con- nective-tissue elements of the nerves undergo marked hypertrophy. In some cases in which the appendix has disappeared Avith the exception of a fibrous string of connective ^^ tissue, ill-defined muscularis and peritoneum, the sclerosed nerves yet keep the patient more or less of an invalid, because they ex- ert an influence which inhibits the peristaltic movements of the colon, and predisposes to constipation, in- testinal fermentation, and general dyspeptic symptoms. I supposed that this influence was due to old adhesions until I found that patients in whom few adhesions existed were relieved from their discomfort and rapidly gained in health and strength Fig. 15.— Single round slough, after the removal of sclerosed ap- pendix remains. Peritonitis is the most important complication of appendicitis, and one which formerly attracted our attention so closely that the appendix Avas often overlooked. The simplest form of peri- tonitis complicating appendicitis is limited to the peritoneum of the appendix and mesappendix. The irritating products of bac- Appendicitis. 27 teria at work within cause a reddening and roughening of the serosa of the appendix and mesappendix. The latter contracts firmly, re- maining contracted and fixed by adhesions if the inflammatory process is severe enough to cause the formation of plastic peritoneal exudates on the layers of the mesappendix. When the leucocytes fail to limit the peritonitis to the region of the appendix, by their anti-toxine, the peri- toneum over near-by structures throws out plastic exudate, and the appendix is entirely surrounded by adhesions which wall it in. This is a very pretty subterfuge on the part of Nature, and it protects the patient unless bacteria have gained too much headway. Nature is appreciative of success, however, and when the bacteria have proven themselves to be very enterprising, she transfers her interests from the patient to the fine colony of bacteria whose claims for vested inter- ests outweigh those of the patient. In such a case the protecting peritoneal exudate is liquefied by the bacteria which escape into the general peritoneal cavity in large quantities, and which excite a diffuse peritonitis if the patient is under the influence of opium. If we help the patient, however, by passing hygroscopic salts through the alimentary tract, and allow natural events to fol- low, toxic fluids are drawn into the intestinal canal by osmosis, and active phagocytosis takes place so rapidly in the broad field of the peritoneum that the patient may be saved. Our intense fear of pus in the peritoneal cavity is unwarranted by present knowledge, and some pus in some peri- toneal cavities is certainly harmless, if we manage the peritoneum well. Before its functions were well understood the peritoneum was often mis- used, and it responded in kind, so that we feared peritonitis. In our day the peritoneum has be- come the surgeon's best friend, and with its aid the most extensive abdominal operations are done with safety. We call it to our aid in 3, 0\ Fig. 16.— Whole appendix, gangrenous and sloughing. 28 Lectures on Appendicitis. walling in the buried stump after the removal of the appendix, and we direct it to dispose of bacteria and toxines. To-day, the peritoneum does yeoman service for or against the patient, according to the dictation of the surgeon. The extent of in- fection in a case of peritonitis with appendicitis bears no direct relation to the extent of destruction in the appendix itself. The most violent peritonitis can occur in cases in which bacteria have migrated out of the appendix by w-ay of the blood-vessels, lym- phatics or loose connective-tissue planes, not going through the walls of the appendix. On the other hand, a very little local peritonitis may suf^ce to wall in a perforated or completely Fig. 17. — Gangrene of mesappendix, A. Appendix not yet dead. B. Mesappendix. sloughing appendix. We therefore over-estimated the relative importance of perforation of the appendix formerly. The fallacy has gone abroad that the appendix is usually destroyed in cases in which abscesses have formed. We opened such abscesses without doing anything further in former years, before the principles in- volved were clearly in mind, and have subsequently removed from these patients appendices which had suffered comparatively little damage. There are certain cases in which it is wise to leave an infected appendix at the bottom of an abscess cavity, but such appendices cannot be left on the theory that they will give no Appendicitis. 29 further trouble after the patient has recovered. In one of my cases, in which a flood of intra-peritoneal pus was discharged by way of the mouth and vagina simultaneously, entering the mouth after perforation of the lung, the patient had subsequent attacks of appendicitis, and the appendix on being finally removed was found to present simply two scar- strictures and a honeycombed lymphoid coat, the outer tube of the appendix being unperforated. When bacteria have liquefied the peritoneal plastic exudate about a walled-in appendix, the peritoneum usually protects by putting up new plastic walls farther and farther away, so that enormous walled-in ab- scesses frequently result. Very often Fig. 18. — Perforated appendix. Fig. 19. — Multiple perforations of appendix. 30 Lect2ircs on Appendicitis. the plastic exudate becomes liquefied by bacteria at several points, leaving firm exudate in the intervals, and we then have multiple abscesses. That fact forms the rational basis for the procedure of separating all adhesions in some operations upon acute appen- dicitis cases with pus. If we evacuate one large abscess, a very small undiscovered abscess may prove fatal to the patient. Intra- peritoneal abscess cavities sometimes fail to evacuate their con- tents spontaneously, or to prove fatal to the patient, and such collections of fluid may remain encapsulated for many years, making the patient an invalid, and subjecting him to the distress of acute exacerbations of inflammation from time to time. If in such encapsulated collections the bacteria kill themselves and their spores with toxines, the sterile fluid and contained debris may undergo absorption. Abscess fluids, whether formed within the peritoneal cavity or in the sub-peritoneal connective tissues, if neglected by the surgeon, may open externally upon the abdo- men, or they may perforate the ureter, the bladder, the bowel, the iliac vessels, or even the pleura and lung. An appendicitis patient with an abscess cavity that is seeking a point for evacua- tion of its contents, is consequently in a most critically dangerous position. A large, intra-peritoneal abscess may form with com- FlG. 20. — Appendix kept partially alive by adhesion circulation after destruction of its artery. paratively little pain, but intense suffering results from abscess formation about the iliac arteries, because the strong pulse gives an unceasing succession of blows to the sensitive structures that are bound to the spot by plastic exudate. When an abscess forms about the large nerves of the pelvis, a distressing neuralgia complicates the case. Adhesion bands are extremely common after recovery from acute appendicitis. The plastic exudate which is thrown out for the protection of the patient may undergo nearly complete absorption if the case is one of short duration, and in other cases short, firm adhesions Appendicitis. ;i remain permanently, but cause little trouble. In a less ffjrtunate group of cases, the adhesions are pulled out into Ioulj bands by '^*%s*-,; Fig. 21. — Interval case. Circulation interfered with by adhesions. the action of the moving viscera. A complication similar to adhesion bands is caused by the omentum, which is very com- monly caught in adhesions at that part of its border which Fig. 22. — Interval case. Three pus cavities formed by scar strictures. A. Pus cavity. B. Scar strictures occluding lumen of appendix. touches the appendix. The movements of the viscera then roll the free mass of omentum up into a rope, or divide it into fila- ments, which, fixed above and below, set a trap for loops of bowel. Adhesion bands cause volvulus and kinking of the bowel. They mechanically inhibit peristalsis of the colon, and strangula- tion of the bowel occurs in such adhesion bands years after an attack of appendicitis has been forgotten, if it was ever recog- nized. The most frequent complications caused by intra-peri- toneal adhesion bands are not the dangerous ones, but consist simply in chronic constipation from mechanical inhibition of peristalsis, or in occasional attacks of distress from temporary incarceration of knuckles of bowel. A phlebitis of the iliac and femoral veins is a common complication of infective appendicitis, and may cause death in a case which is otherwise a moderate one. Acute suppurative nephritis may suddenly appear in a very sim- 32 Lectures on Appendicitis. pie case of appendicitis by infection travelling up the ureter. I lost one such patient, a student who came into the office smiling, with his books under his arm, and saying that his physician thought he had appendicitis, and wished to have me see the case, I found an appendix somewhat tender and firm with interstitial exudate, but the patient had no constitutional symptoms of in- fection. I asked him to enter the hospital the next day and have the appendix out. When I saw the patient on the follow- ing day, he was in a hopeless condition from acute suppurative nephritis, which proved fatal. Fig. 23. — Post-appendicitis adhesion band from cecum snaring a loop of ileum. Septic pleuritis and pneumonitis suddenly and unexpectedly develop in any stage of progress of infective appendicitis. Tuber- culosis and neomata of the appendix are not often complicated by infective appendicitis, because the progress of these diseases is slow, and the structures of the appendix have ample time to ad- Appendicitis. 33 just themselves to the new conditions, just as they do in hydrap- pendix where slowly accumulated mucus, dammed by a stricture and sterile from suicide of its bacteria, gradually forces the lym- phatics and blood-vessels to become hypertrophic in a compensa- tory way. Such compensatory hypertrophy and multiplication of structures is impossible under ordinary conditions of acute infec- tion. Catarrhal appendicitis has not been observed by me as yet, because I differentiate infective appendicitis from catarrhal colitis with involvement of the appendix, and do not operate in the latter cases, nor do I call them cases of appendicitis. When I operate it is upon cases of infective appendicitis in various stages of progress, and the responsibility that goes with the making of a diagnosis is such that I believe it to be morally wrong for us to make the diagnosis of catarrhal appendicitis at the bedside before the specimen has been seen. The simplest stage of infective ap- pendicitis, and one which is perhaps most often wrongly called catarrhal appendicitis, causes symptoms when exudate-compres- sion-anemia and toxic destruction of cells cause a small portion of the inner tube of the appendix to disappear by ulceration, or by sloughing, before the resistance factors are in control of the tissues. When infection halts, the gap left in the tissues of the inner tube is closed by granulation, and eventually by connective tissue, which slowly contracts and narrows or closes the lumen of the appendix. In such a case the patient may be free from symptoms of appendi- citis in two or three days, but the progress of mild infective appendi- citis is often protracted, and marked by slow erosion of mucosa and lymphoid tissue, caused by pressure of interstitial exudates ; by muscular spasm of the outer tube, by obliterating hyperplasia of the tunica intima of small arterial branches, by plugging of lymph channels, or by direct toxic destruction of cells. Connective tissue gradually replaces the broken-down inner tube, and if it is ■evenly replaced without the formation of stricture nodes, the dis- ease may eventually disappear without causing disaster or even very marked symptoms. In these chronic cases of infective ap- pendicitis, all structures excepting the mucosa frequently become excessively hypertrophic during the period of infection, but finally nothing remains excepting a string of connective tissue surrounded by ill-defined remains of muscle and peritoneum, and containing sclerotic nerves. We cannot reasonably expect that any particu- lar case of appendicitis will end in this way, because the accidents of acute exacerbations of the infection too often bring the case 3 34 Lectures on Appendicitis. to a more abrupt termination. In the more vicious forms of acute infective appendicitis, all structures of the appendix are partly or wholly destroyed quickly. If the appendix is well walled in with plastic lymph, the sloughs which form are decomposed by sapro- phytes, and. the stump of the appendix or the opening in the cecum gradually heals. Rhexis of the appendix, a condition in Fig. 24. — Rhexis of middle segment of appendix — A. which the capillary vessels allow their contents to escape inter- stitially into all the structures of the appendix, dissecting tissues apart, and distending structures with blood, indicates a savage type of infection, but one which occasionally fails to give symp- toms of importance until the condition of gangrene supervenes. Appendicitis occurs principally in young males. The fact that women do not suffer from this disease so often as men has been well established by post-mortem examination statistics, and is not based on the theory that in women diseases of the ovaries and ovi- ducts are more often mistaken for appendicitis, because such mistakes in diagnosis are easily avoided. There are three fairly good reasons why women suffer less often from appendi- citis, viz. : (i) There is sometimes collateral circulation by way of the appendiculo-ovarian ligament ; (2) women expose them- selves less to the production of traumatic infection atria ; and (3) the flaring pelvis in women is not so likely to hold a displaced appendix in a cramped position. About twenty per cent, of the cases of appendicitis occur in women. It is most common in both sexes between the ages of ten and thirty-five. But it may occur Appendicitis. 3 5 in the infant at the breast, or in the old man in his dotage. The very young, and those past middle life, expose themselves less often to the production of traumatic infection atria. Another reason why the disease occurs more rarely after middle age is be- cause the appendix undergoes a certain involution process, which sometimes leaves it bare of mucosa and lymphoid tissue in old age. A nomenclature has been sought for the description of various kinds of appendicitis, but apparently there is only one kind of appendicitis which produces acute symptoms, — infective, exuda- tive appendicitis, — caused by bacterial invasion of a structure which is peculiarly unfitted to resist the effects of such an inva- sion. The various phenomena of infective appendicitis should not be described as indicating different kinds of appendicitis, but rather as marking different forms of one kind of disease. Thus we may speak of the acute or chronic form, the form of endo- appendicitis, or of perforation, or of hydrappendix, and so on in- definitely ; but as endo-appendicitis may be present on Monday and perforating appendicitis may appear on Wednesday in the same case without our being able to state what Friday appen- dicitis may be like, we might classify these cases as " Monday," " Wednesday," and " Friday " appendicitis. The diagnosis in each case would be made afterward. We cannot know that any attack of infective appendicitis will stop at any one form short of complete destruction, because the power of the principal resist- ance factor in any one case is absolutely unknown. By " resist- ance factor " I mean so-called phagocytosis. We can place a case in a certain sort of classification after we have seen the specimen^ but such a post-diagnosis is not more fair than a game of whist after an opponent's hand has been seen. If we classify cases as fulminating cases, or as cases with abscess, we are classifying them from the symptoms of complications without reference to the actual condition of the appendix, or the form of the appendicitis proper. There are no groups of symptoms which will allow us to make a rational prognosis as to the eventual outcome, or the prospec- tive complications in any progressing case of appendicitis, and we must abandon the hope of having any such classification of symptoms for a guide in the future. Attempts will be made from time to time to classify symptoms for prognosis from small groups of cases, but they will fail because of the nature of the disease. 36 Lectures on- Appcndiciiis. I speak, then, unequivocally, knowing that some patients are to die and others are to suffer unnecessarily because their advasers will believe themselves to be upon a prognostic track. There is but one rule to be followed, and that is to isolate an infected appendix as. promptly as we would isolate a case of diphtheria and for practically the same reasons, viz. : the infected appendix will probably infect other structures, and the infected throat is likely to infect other throats. An infected appendix is isolated when it is out of the patient. All cases of appendicitis that are otherwise wathin surgical limitations, and that are within reach of competent surgical services, are cases for prompt isolation of the appendix. Various periods of waiting have been tried with the effect of proving that the question is wedge-shaped, with the greatest number of deaths at the broad waiting end, and the smallest number of deaths at the point of isolating an infected appendix while infection is limited to the confines of the appendix. We are held to our rule by two cardinal principles, viz. : (i) Every hour of progress of any acute attack of appendicitis means in- creased damage to viscera ; and (2) with no infected appendix the patient would have no complications of appendicitis, and there- fore the patient would have no complications of appendicitis if we leave him with no infected appendix. It then becomes a matter of interest to note the comparison between the death-rate of medical and surgical treatment of appendicitis. Statistics from a large number of observers give an average death-rate in the prin- cipal attack of appendicitis of about fifteen per cent, under medi- cal treatment, and I assume from experience, without being able to obtain available data for reference, that nearly ten per cent, more die from the numerous chronic complications resulting from previous acute attacks. According to Bull's statistics, from a large number of selected operators, the surgical death-rate of appendicitis is not far from two per cent, in cases operated upon at a time when infection is limited to the confines of the appen- dix. Bull's statistics, however, include only " interval cases" — cases which were already of the complicated class. I believe that a surgical death-rate of two per cent, is illegitimate in cases oper- ated upon in the first attack before infection has extended beyond the confines of the appendix. If the surgical death-rate were fourteen per cent, and the medical death-rate fifteen per cent. our duty Avould still be clear. We have learned that the peri- toneum is not to be feared by the surgeon in such cases, and now Appendicitis. t^j that we know the possible dangers of ligating the appendix h'ke an artery, there are no further dangers in sight excepting from an imperfect aseptic technique, a responsibihty which rests with the individual surgeon, and from ordinary causes which have no direct connection with the appendicitis. From experience I judge that we must place the surgical standard at less than one per cent, mortality rate in cases of appendicitis operated upon by skilled operators at the proper time for removal of infected appendices. The surgical treatment of appendicitis has made three distinct steps in progress within the past decade. Ten years ago we simply opened the abscesses of appendicitis when they were strongly in evidence. The first planned operations for the removal of infected appendices were done about the time when Dr. Fitz, of Boston, gave a great impetus to the investigation of the subject in his classical paper in the American yoiirnal of the Medical Sciences in 1886. Intense interest in the subject w^as soon aroused, and surgeons generally began to search for infected appendices, but at such a late stage in the progress of the disease that statis- tics at first showed little if any advantage in favor of surgical treatment. The reason for that was because infection at the time chosen for operation was beyond the reach of resources of the surgery of that day. Then came the period of operating in the interval between attacks, or in the early stages of the first attack, and statistics at once showed the very great advantages of this treatment. There remained then only the necessity for perfecting the operation in such a way as to avoid the occurrence of post-opera- tive ventral hernias and of unsightly scars, and this has now been done. Medical treatment, which cannot reach the bacteria that are invading the tissues in the appendix, will nevertheless give very decided comfort in many cases in which surgical services are not obtainable. Opium will cover up distressing symptoms, and allay the feeling of unrest which is very marked in appendicitis. Hot fomentations over the inguinal region will relax the exhaust- ing spasm of the abdominal muscles, and may sometimes relax the outer tube of the appendix temporarily, but the tonic spasm of the muscular tube of the appendix is caused by direct toxic irritation, whereas the tonic spasm of the abdominal muscles is sympathetic, and due to a reflex from the appendix region. The orthopedists are the only members of our profession who, as a 38 Lectures oil Appendicitis. class, are able to appreciate the exhausting effect and the disas- trous influence of long-continued muscular spasm. When hot fomentations fail to relax the muscles of the anterior walls of the abdomen completely, we may be quite sure that muscular spasm of the outer tube of the appendix is persisting down below, unless that outer tube is destroyed or paralyzed by interstitial exudates. Olive oil or saline cathartics passed through the alimentary tract will remove fermenting intestinal contents, and decidedly lessen the so-called auto-intoxication which is an element of much importance in these cases. Personally, I should prefer the saline cathartics for the purpose, but the Homeopathists have used olive oil with success for a great many years, and we may rest assured that its popularity with them is based upon observations of its usefulness. By usefulness I mean the obtaining of comfort for the patient. His chances for recovery are not much improved by any treatment which fails to remove the nest of infection, and that nest is out of the road of medical resources in appendicitis. So many patients will recover from one or more attacks without any treatment of any sort that Ave are apt to be misled as to the value of medical treatment excepting as to the comfort which it gives a distressed patient. Appendicitis patients who are in a position to receive surgical treatment should have very little preparatory medical treatment. Opium is to be particularly avoided, especially if the case is compli- cated by peritonitis. We need to have the peritoneum active if it is to serve the surgeon well. With an active peritoneum we may open the abdomen and remove the tubular tonsil almost as safely as we open the mouth and remove the flat tonsil, provided that the operator is expert. Our recognition of the safety of such work under the principles of new surgery would tempt us to remove the normal appendix when it appears in the field of our other abdominal work. To this I am opposed on the principle that the death-rate of no surgical operation can be reduced absolutely to zero, and the surgeon who would protect his patient must not remove an appen- dix until there is infection, and consequent occasion for removing it. I refuse to remove uninfected appendices, and can find at the same time no rational excuse for failing to promptly remove infected appendices. The cause of prompt operative treatment for appendicitis has had to labor against the prejudice aroused by unnecessary ovarian surgery, just as diphtheria anti-toxine to-day Appendicitis. 39 has to labor against the reaction which followed the trial of Koch's lymph. The operative treatment of inflamed ovaries and tubes had a pendulum movement — too many operations were done because the reasons for operating were not always founded on a sufficiently rational basis. Then came a reaction, and to-day, not enough operations are done in some localities. Eventually the equilibrium will be found. The treatment of infected appendices has never had any pendulum simile, but rather the simile of a door which has gradually closed upon the question of immediate opera- tion, leaving it no longer an open one. An inflamed ovary seldom threatens life unless it is the seat of a dangerous neoma or abscess ; it usually responds to palliative treatment, and may be a very useful organ. An appendix, on the other hand, is never a useful organ, and it always threatens life when infected. I frequently spend half an hour in the attempt to save a damaged ovary, separating adhesions, freeing agglutinated fimbriae, and opening a closed oviduct, instead of removing the mass, which at first looks so unpromising. With the damaged appendix I spend only time enough for its removal. Sometimes when engaged in other abdominal work I find phosphatic or fecal concretions in appendices, and liberate them by pushing them through into the cecum, not disturbing the appendix if it shows no evidence of infection. In some cases so-called ovarian neuralgia could have been relieved if the surgeon, on finding a normal ovary, had turned to the appendix and liberated a concretion. It is rather unsafe to leave an appendix which has contained a concretion, unless the surgeon is familiar with the appearance of normal appendices, and it is only within the past year that I have dared to do it. There is one position in which the surgeon may hesitate about operating when he finds a far advanced case of appendicitis at his first visit, and that is in a town where the people are not likely to distinguish between Xht post hoc and XhQ propter hoc, if the patient dies after the operation, and not because of the operation. The surgeon knows if he waits for the bacteria to kill themselves by their toxines, or to be killed by the anti-toxines, he can remove the appendix with safety as an " interval case." He also knows that the patient may die before the bacteria cease work in that particu- lar case. If he operates, and the patient dies because bacteria were in advance of surgical resources, all operating for appen- dicitis may be stopped in that town, and lives may be lost, and much unnecessary suffering will ensue because the people will 40 Lectures oii Appendieiiis. fail to avail themselves of proper resources at a proper time. Consequently, as a matter of policy, the surgeon may find it right to adapt himself to his surroundings, and to sacrifice the indi- vidual patient by refusing to give him help, — in the interest of the public. More lives will really be saved in such a town if in such a case we refuse to give a father a chance to live for his family, or refuse to try to help a son who is the sole support of aged parents. This picture is by no means a fanciful one, as we all know very well. Personally, I have never been able to refuse to help the individual, and other patients have been lost from neglect because a far advanced case of appendicitis died in spite of all the resources which could be applied. No such opprobrium follows the death of an appendicitis patient under medical treatment. The progress which has been made in the treatment of appendicitis has been based on accurate information relating to the problems that are involved, just as we have made recent progress in many other lines. Not many years ago, when a woman came into the office complaining of sick-headache, or nervous dyspepsia, we thought first of medical treatment, and such medical treatment was usu- ally unsatisfactory because we obtained temporary relief only from the treatment of symptoms. To-day, in making a diagnosis by exclusion in such a case, we are called upon to eliminate the possibilities of irritation from errors of refraction or inflamed rec- tal papillae, or a uterus out of position, or septic oviducts, or a loose kidney, or carious teeth, or hypertrophies of the turbinated bones ; and the proportion of such cases that are found to be essentially surgical is very large. The insane asylums are now robbed of many of their victims by our present knowledge of the accurate methods of giving relief — a knowledge which makes it easy for the patient and difficult for the physician, in contra-dis- tinction to the not very old plan which was easy for the physician, and hard for the patient. Our advances in the field of appendi- citis, however, now make treatment easy for both physician and patient. Ten years ago most of our appendicitis cases were treated under the aliases of acute indigestion, bilious colic, mala- rial fever, la grippe, peritonitis, entero-colitis, cecitis, neuralgia of the bowel, intussusception, volvulus, intestinal obstruction, typhli- tis, perityphlitis, typhoid fever, salpingitis, ovaritis, gall-stones or gravel ; while some of the abscess complications caused the cases to be classed as psoas abscess, coxitis, abscess of the abdominal Appendicitis. 4 1 wall, peri-hepatitis or peri-nephritis. Appendicitis is of such common occurrence that we have all lost friends and acquaint- ances from that disease, and such multitudinous forms of abdom- inal disease are simulated by appendicitis that we must press with our fingers at "■ McBurney's point " in almost any case of acute abdominal inflammation of sudden onset as regularly as we would look at the tongue. I have seen appendicitis overlooked on post- mortem examination in former years, because the appendix hap- pened to be buried in adhesions, and because it was only a little thing anyway ! The symptoms of appendicitis do not indicate the condition of the appendix more closely than they do the condition of the in- fected wisdom tooth in which a very small carious point of infec- tion may excite an intolerable neuralgia, or it may be the cause of suppurative alveolar disease, pyemia, septic meningitis or abscess of the neck. Another wisdom tooth may become entirely carious without giving any symptoms beyond an occasional tooth- ache. We may find a completely gangrenous appendix in a case in which the patient is resting quietly in bed with normal tem- perature, pulse, and respiration. The reason why the appendix is free from tenderness is because it is dead, nerves and all. The temperature and pulse are normal because toxines are not escap- ing into the general circulation. The face of such a patient, however, usually looks " wrong " to the members of his family. In another case with trifling ulceration of a part of the inner tube of the appendix we may find the patient throwing himself out of bed on the floor, rolling in agony, and striking himself upon the head with any near object in an insanity of pain from irregular spasm of the muscular coats of the intestine, otherwise known as colic. His temperature may be 103° F., and his pulse rapid. Such extreme cases as the above two are seen by all of us who are engaged much in abdominal work. The presence or absence of an inguinal tumor is a matter which must not be taken into consideration in estimating the value of the testimony of symp- toms, because an acute general peritonitis may appear in a case of appendicitis in which the appendix is not perforated, and not surrounded by plastic lymph ; and a perforated or dead appendix may be walled-in by plastic lymph which is barely sufUcient to close the opening or surround the slough. In the latter case there is danger in an examination for tumor, unless the surgeon is prepared for immediate operation when he has accidentally separated the 42 Lcctiti'cs on Appendicitis. frail adhesions in making an examination. On the other hand, a large mass of plastic exudate may form about an appendix which is whole, or perforated, or sloughing in its entirety. For these reasons the presence or absence of an inguinal tumor is not impor- tant as giving a clue to the condition of the appendix itself. The groups of symptoms which belong to the various forms or com- plications of appendicitis are so multitudinous as to be extremely confusing to one who attempts to study the subject from the elaborate descriptions of authors, unless he has had considerable practical experience ; and yet the disease is diagnosticated as readily as a broken leg by any one who has accustomed himself to looking for it. The correctness of such diagnoses are verified by operation. In most cases of appendicitis, the surgeon is guided well by certain symptoms which are of pretty regular occurrence, and in order to give a clear view I will adopt the plan of describing one typical case only. TYPICAL CASE FIRST DAY. Subjective Symptoms . {a) General abdominal pain of sudden onset. [l)) Waves of colic. [c) Nausea and vomiting. (d) Tenderness on finger-point pressure at McBurney's point. Objective Signs on Palpation aiid Inspection. ( ^ ^ 'Zi 0) CO ■-'^ ^ >, . >-. ^ lU rt w-> u i^ > D a >^ D 7: J; oj S IS Sloughi nal ob neurosi skin an [55 g .s « O H o ,_; , <1) U > ^ , H 5 OJ ;— 0; :; S ■/: W u .s >> > C "^ •jaqmn^ 70 Lcditrcs oil Appendicitis. "3 Pi u > o Recovery. 1 ID > O o ^ s O lU Ci- I-i a" 5 > o (U Recovery. Small fecal fistula yet. Two years elapsed. > o 'J D r/ > o o 0! 6 o U > c •:: 2| O o- o X « - Hi .- — 5 - - 4=: u .5 > t: rt r- aj >- .S a- = ^ ■s. ~~ c .2 u a O 1 "3 o £ ci. u .S TJ "C 4-1 > :2 ^ o o ^ s ^ 3 o 3: U 3 'o b/3 O if ^ 6 J > r-' "IJ O c • . •^ E ^ -^^ -S -^ "= g s a; 2 "^-^ v-^B UTS « 't::'±: .S xW ;::; 3 = (U-- o o 2 C p. ^ -^ .^2 .S c in 11 •" .2 "2 m'2 § CSS P ? aj "- "Tj > OJ 5 '2'S-c .;; -.2 aj b/) ^-'n .2 _u "q. 6 o U -a c 1 •^^ s t <.^ o ■ 2 c Is D .1=. E Jill S 0! o 3 d ^ L6 B •r ni " a s ,^ '=^ tJ ^ s/: " — i> c o 20|| 1 ^' : ^." • c ^ t- o S 3 0) 1> ^ o p, ci.Ph oi i ^ 'o i2 = .2 .^' '^ %. §1 § 1- .S JO -C JD oi O 1 ^ 2t3 'S'2 S >^ p .il. *-« .s ^« 111 3 2^ c o U •G C o c 3 D s 3 "3 o E 5 " 5 5 - E O lU . ■r Q vh wi = Mo 8 i^ u = c cuo > U 0) O-rC J} 1 ^• ■Ji o -2 S ~ — ■ '2 (U ..-, 2 S > 't; aj . -C ^ ^§ 'i ^ L4 o X c — o (U o _X^ -5 ■" 53 '2 II • «* S^' "rt ^' 3 > (U OJ S S 3 X 'i;; '5 2 I.I % s § j^ |<; S ^ ^' vO en r^ •* en o en •JO-;!!!!!^ o M M CO :i? O >-* Surgical Trealnieiit of Appendicili^ o F^ -r; ^ g U] VI >>•- S rt -c > -r !> -^ u O y, -; '._i. • (U (D CI ^ O rt (U ^^ f- K-_ <■*-( .j:^ rt > 3 O (D C 3 x; (U T5 ^ T) S c « S (U ■" u "7 ^ ^ ^ ■i 3 0/-I: -c = ti t: c t3 J <»^ 2 ^ E ^ rt ■ 2 rt = ^ ;« X o ■" ;^ C n 03 ^ '5 "3 _. ■ 2 «^ b^-^ = 0) o " -r o £ ^ 5 r^ O Si ?i .5 S ^ 3- ^ .^S-g-^ -a "? "2-2 M 13 53 S S.= , !^ 7^ ^ .; a- " TS "^ c ^g^^-S -w '^ O rt u .p- be « S5-gEi- =s I— J £q ir. % ^ M o < w J -^ 'in i-* 2- O '^ .i; -^ > o o 5 53 '[H s -ti O Vi r- O '- ^ 2 53^ JJ o .;: ui ;; T o li; ^ ^ g .0 o ii •■§ "? 'u o JL .=; li: W &H p -3 ^^Z I 5 '^ ■5 .S oJ o M -J" "5 p"!? ^ C -3 ■Zi g g ID 'rt ,0 72 Lcctitrcs oil Appcjidicitis. !0 o S lb I 1) r- iL) !-. 2.5 3 I ^ fl "o E — < "" 1) oj <33 P rr -^ 2 c " -_aj ^ ^ ^i6 :" o C (u a,-c ^ p " " ° CIh S C u p^ 8 = . G X « _• i) -M o ;i: o ^ — _ 5 > , >^ >^ >^"~^ 4) >. >, >^ ^,i3 u u > > > > > o r; r^ o JJ^^ 'O u (U (U u D 0) e^; ^i; i:^; f^ P^ P^ — - r^ 1 -tJ •"llc^o t^ (U ^ " -tn r ^ g^l^S" lion ew supp thin cavit •s-H S;h nother which buried s 5ut sutur tures wo later. rimary u lowed ne later by tion wit dominal Opened, drain. rimary u lowed f later by tion wi dominal < ^ Ph , 3 Ti Pi -a OS o i C i fc'i oj « o - ^ « ^ .o <0 r-5 1^ ai J^ G (D r- KA > 3 r- 3 C3 ^J ^ n I* — . O -S OJ ■ O fi( t/1 tn s 53 3 o a.:Ji h-l (1) ■^ u -S > c tn-^ u 0) z3 C3 CD 5^ in > ti -"^^^ r^; '^ ■-' >. % 'a •' 53 P^ T3 u ">< ^ t^ .-s < s tj:^ s u S C " -= -^ ^ rt u J= rO •0 ■u -c C p =« ?^ t; - 5 g"? o| i ^ S o ?^^ — ?; ^ U O S.-T3 13! Ti . S S I -c' O j; _U .^ "3 H M o .;2 « •= 5 E?^.2 S ^"^ j=7: U - D O u 1) > > u > •J > u u 6 > c u Post-Operative Com- plications. Hernia appeared in wound some months later. Hernial opening closedbyDr. Coley. Sepitic peritonitis. Another case in which silk-worm gut sutures slowly worked out. Operation. Incision i^ inches long. Re- moved appendix. Buried stump. Closed wound. Incision i^ inches long. Re- moved appendix. Buried stump. Closed wound. Incision 1^ inches long. Re- moved appendix. Buried stump. Closed wound. Incision \\ inches long. Re- moved appendix. Buried stump. Drained wound. Incision i^ inches long. Re- moved appendix. Buried stump. Drained wound. Long incision. Removed ap- pendix. Could not bury stump. Ligated it. Wick drain for oozing from torn adhesions. Long incision. Removed pyo- genic sac. Wick drain for oozing from adhesions. Stage and Complications. Acute. Well marked new ad- hesions. Adhesion band from tip of appendix to mesocolon was strangulating cecum. £ ;d 'o > B S X 0.2 3 0) v-i '•^ U Tuberculosis of peritoneum not including that of appendix particularly. E .2 'Tn , u OJ 3 3 P > X . 3 (U 9 :B '^ Number of Acute Attacks and Con- dition of Appendi.v. One? Round slough, penetrat- ing middle segment of inner tube. Several. Hydrappendix. Scar stricture near cecum closed lumen. Lumen distended with several drachms of clear thin fluid. One. Appendix nearly dis- appeared. Small portion of lumen and portion of outer tube remained. ^.2 s s s^ I s •J 2i -5 ? 5, 3^ JJ rt d -^ J- CU O > O tn 2 D o ■ii bn U "c « in t/} • '^ -v. t- HJ ^ h) ^ .a cS O .w . C c: O 3 •-' . o 05.2 ^ o r. 0) fi j; "^ D-' — ' Ct3 o^ O D c Oi O ;3 rn !% Tl XJ O (11 a, o •^ Oh H« Oj U M C -73 n (U S 71 > o bJ5 ^ .ii ■ O in TS ■ TJ D ' bD A >^ . ' '=^0-'= C 3 - o S O " S -e fe X O &.— I 1-1 u id o o UI Ul C o .2 (U T3 <^ ^ n O u U ^4^ rC O CJ U < iyj ,^ -^ C V 02 ■-D rt y) U -gs . C D S > 2 o r.s H v: < S^ b/3 (U _E o .j2 _-^ ^ 3 > t^ o (L> ^ CI. o ^ a. Z =- o ^ m 1-. =5 y t: i; e o ^-^ " 5: ^y C D l- ,^ 3 iJ: 4) O >^ <£ Cue S "3.2 as ^ c = tl. (U cr s Q_ j f^'c IJ O ^ o 'o U-) r^ ->■ i-r :c •3- (N c^ 1 ^ 1 ^ c<-i cn M " t^ CO o o M N en 1 ^ in rr ■* 'J- in in "^ in 1 "^ i ^ 76 Lcc hires oil Appendicitis. 3 > o > u 4) > u 2i > o 0) > o > o CJ 1) > D -/ > > CJ Recovery. S aj "3 ^2 CJ a> 1) ^ s o > •S o O 0. J) o U. 1 r^ • o G..:; t:: == S^ ^ p- 2 f^ 53 &.1«> c .0 i o. O ^ '-rt O O u S «> (D > • o o u Cits 13 .« . tJD T3 C C O 3 O 5j 1) H .2 ^ p^ •e §2 c e M .W . tifl T3 § § " . O .y, X > ^ 5 S^ ,-|M rt (J M o 2 is 'A r— 1 ^, rt o -►^ u Ti 1J o ^ pt.t: y S « i: ' — 1 J-t 3 .m . t/; Ts c c s — ' . m X > y S Si ■^ &-2 rH|M CS U M 2 •7-03 .m . 5 CJ (u HJ ■" aJ III 2 Si?; ^1 .35 . b/3 -TS ^ . =^ X aj -TD "^ -G = 'T3 CJ u < c 'a 1° i > '55 2 o U T3 C3 aj o < "o > c o S I- o U ol) > ■35 c £ W || -a u "0 p '0 • CJ •« § 2 u CJ U3 CJ r- 1) •<^ c C3 *" c 0) 13 CS CJ* 'S 6 en 0^ tJ i-, 1) ,^ 13 1) 53 . 'S aJ . « 3 (U c o O •a c ^i o c B U 3 O t^ s 3 5 =" 2i 1^1 . lu o 5^ aj fc/) fe CL w O t3 o V) .-^^ 2 > o e C^ CL, I3i II > 2 5 C II o 1-5 a, — 3 u <-. CO tJj'cS aj CJ w a; D ^.5 3-G 2 tin . ^11 ^N ■£2 5 c Ji oi « cd 6^^ C!i ^aJ -« 2 0) 0) 2'o _X iJ D S -^ c (J ■ n "^ x' S § § ^' S" § s s §■ s O 1 CO in 'o N 1 t lo CO T 1 to j -1 i-H ^ ^ •a3qmnfy[ vO ^ -o ih CO Surgical Treatment oj Appendicitis. 77 1 1 '/■; 1 a; n — 1 3 — 5 i^ §■ = .'{i . '^ CO sA >» >-» >-, >> >^ ^« ? >^ i~* 1-1 u " -^ ^ > > > > > > n ?2 > o o o u u o o o 'J u o « (D o (U 1) 1* O .S "u D f^ ^ ^/ -/■ '/ -y -y ^/ 1 - ^- r- U< ^i rt ? rt if -5 t-fi"^ ^ ^ •- O (u rt s ° ?="" -^ ? u|„.S ^ . 3 o "■Goo u ■-:^ Oh H .§- oCJ-o" ^ (U -^ (U s • '^ ^ X t.[. ^ > D .ti u in t/] ■ • < -^ ^ ni rt ^ ^"vii O JJ .;3 o 1- ■'i C m O lo ^ en en 1 i-i C) d C^ cn 78 Lechu'cs on Appendicitis, "3 rt c in to . 013 Recovery. Recovery. > U 1) > 'J u S > Died 5 days later. Acute suppurative nephritis. > u u 5 O u ui > C •3 S3g OP. o •3| s '^ S a, 1— 1 ifl t/j . (U ^ g t3 r- ;« a c o o u c O rt 5 " 3 l-l ,^ u .0 ^- •S/'O g 'G "o .5 ><■ . " rlfil . !>^ "^ C 'T^ t/5 S C 0) •^ jj .a G. ^ ■*-' E^ e 4-1 C3 5-1? = .2 '" S'5 u p^ .h ■^ t; • E - S 75 2 'D a, d. s §11 i ^ 53 55 f^ t- 000 •^ S . X- >^'fi w-i d 33 S.2 -^ g y >lj (u -u p „• II b/) . oJ _o ^*^ '0 ^ i1 3 .« . 1 .§ CJ oj c c a. 71 .,- 0, .2^5^- •el 2 E fi 73 c d E o O ■o c 1 > " ?^ 73 0) U . S _!, ■Si 5 S t/) . c w '^ 7)' ill '^-^'^ ■^■^^ 0^ > .^ 2 "3 1 X g ■*- 0) (U J -S ■:;: i^ •0 a .2 > -73 13.2 > 71 r- U ■Id "0 71 T3 C < X u^ CL, > . at JJ . Bl =1 u 3 O -a c 11 <=^ 3 O <| .a 5 71 u 'J _g IS i| a 53- t^ '"J W oj 1^ . cJ 'E 2 "^ 5 S/- u " ? > •- D P C/2 U S lU 1?; ;; £." i4 C S D 1) 5 ^ C oi —1 2 • 53 U p. 0) 2 I) 5 3 bo ;;: ■rj 71 £ 5 'i3 D — a c c m ^ t: 72 u 73 3 53 u txi c ci 6 53 5 a 3 Ctf (U !_ 71 J3 - _^ J= .CO t; — ' 71 (u 'r: 3 soS^a Ti-lig (U C^ r^ r^ % '^ ^ S |S p^ |S u < N M CO rj- CO CO -J- 1 u-> N ! M M CO C4 M •jaquini<[ 1 t^ t^ ICO ex. 00 Surgical Treatment of Appendicitis. 79 jj O , ■3 9- = c S 3 53 =1 P o 5 ° ii -" C3 >-. fi ?i CI, X T3 . Png C &! .2 c '> o o C (U S > • u3 c ■' a !> O b/3 .2 ^ rt tn O o a> '5=1 u rP "> r-J P p c S'2 .2 Ji.o S, rP O- I/I ■« ^ 1) 'T3 O (D dj ^M=«U 2 ^ g^ i2 o 3 " p -s p p 1" O CD U P Dh S u yj -- PhcL • R rt so f tJ p « TS OJ > w ffi o CJ a ti +j ^ >-, p' h-l Xi O o X p 1-1 o in D Tl W P s ..-] rrt o cxOo^l ^ CL,0 in r-! o ■3 p 1) 'u rP "o p O > (U b/jK' 1 Q rt O _5 '5 OJ P .2 6 ,^ IJ OJ b;3 D CL, p p P &,n (U CJ rt CJ f- K-l c 1) ^" O "S .P '-I ^ ^-^^ p p > 2 5"^ in Sh S X « = ;pO tJ3 P M P 1) l-H in 1 3 ^ cS O tn i r^ CJ -rH O in in in rt Td "13 ^ -P 5 -p ^ o -p X, o s ^ CJ p < Several. Sclerotic stump. Appendix replaced by masses of tubercle. History of in- flammation beginning at ap- pendix. OJ p '0 _o % u 5 '2" 6 D rP > 3 bO (U _x ■^ 0) CI- < p OJ 0) p 5 •P b/3 V" >^ -r, P OJ .2 ^ 'c^ rS fe 2 5 a" >> (U ,P > p OJ -w Two. Three complete stric- ture nodes. Internodes dis- tended with purulent fluid. Several. Gangrenous and per- forated at tip. One large con- cretion. 6 b/] _X p 0) CL, 2 One. Appendix gangrenous and perforated at several points. i % OJ ;-< bO P c3 bjO _x -5 p 0) 6 1 . i . ! . 1 1^ s L- '^- L- L- 2 j§ |S ,-^ ,^ r^ M 00 -t- CO IN w ^ ! rO CO (N CO OO c» 00 XT) CO c« cc CO CO CO 8o Lectures on Appendicitis, ■3 Recovery. Recovery. >> > u u U u >• 8 Recovery. > (U p^ E u •z C 0. ^2 i curt H 1 1 t^ ^ rt .S? .^ ^^ i1 '-^ u 3 .pq . 5 x' § M • ii s ^ £-K M 22 ^ "35 •S .X "^ %t.6 ■| .2 3 •i2 £ K " ts >, .2 fi . c ^ .S X ^ "^ X A '>^ G- t^ tJ) C3 g OJ 1^ g 2 S 0) ~ .^>£ "^ c'-l ^ 2 •£■" fix c; txS.y fi fi <">■ 2 e-;>>i: x' -d ^M t^ * 03 1 3 '0 "m s .2 "ifi S ^£ c " CIh > s 1J C 'o u _> c if X w 1"^ 1 s X H ^ u5 J. 2 rt ii ^ 1 ;/) S •2 rfl C 13 c 1! IS V4£ i <; c "^ ■> C r- C ni 3 fe £ ;> « ^ > 2 >- :-' in 6 s :i ^-^^ &| '0 X ^ . ^ s c E t; "J (!) S-. ^ X .2 S-'-' '> < b^ in cj .S ^ •,= c! 1;; - " 3 ^^ " • >>'3 ^ " s" 52 _o ^• .N 'l/l Ih rt rt 's £/^ ^