No. 3804.

JULY 25, 1896.

An AddressON

THE MILDER VARIETIES OFAPPENDICITIS.

Delivered before the Metropolitan Counties Branch of theBritish Medical Association, West London District,

on April 23rd,

BY W. ARBUTHNOT LANE, M.S., F.R.C.S.,ASSISTANT SURGEON AND LECTURER ON ANATOMY AT GUY’S HOS-

PITAL; ASSISTANT SURGEON AT THE HOSPITAL FOR SICKCHILDREN, GREAT ORMOND-STREET, ETC.

GENTLEMEN,-I propose in this address to place clearly a

i.before you the several clinical and pathological conditions Iwhich may be fairly comprised under the term appendicitis, 1

which I understand to mean some inflammatory condition of 1,the vermiform appendix, the intensity of which varies within asuch wide limits as to be scarcely pereeptible in some, t

a

while in others it results in a gangrenous process. I twould point out first to you that the primary, and iindeed the only, cause of this inflammation is the pre- c

sence of some fascal or other matter in the appendix. rThe material may be an ordinary firm mass of freces 1

which the appendix is unable to get rid of, and this 1 z a

’believe is much the commonest cause. Or it may be (

ireces so altered by gradual accumulation, compression, a

and desiccation as to form a hard, elongated, more or 1less laminated mass, which is often described. In a Ifew cases the mass in the appendix may consist of some I

indigestible or more, or less accidental matter, such as a i-date or a cherry stone ; but these are rare causes and fare only seen in the worst kind of appendical cases. {

It is not necessary that the cause of the irritation should I

oe solid, and,’ in fact, I have operated on many cases in I

which it was obvious that fluid fasces dammed up in the.appendix were able to produce considerable irritation, though 1usually of a less violent character than that produced by 1.a solid plug. I think that we may assume that some 1appendages, either from their length, their manner of i

.attachment, or their degree of mobility, are more liableto become obstructed by fasces than others. As a matter (,of experience, I have found that the very long appendix,which moves freely within wide limits, dropping usually’Into the pelvis in the supine posture and behind or cjust external to the external abdominal ring in the I- erect posture, is that most liable to become twistedand blocked with fluid fasces. It is, of course, quiteobvious that after the lumen of the appendix has been

partly or completely occluded at one or more points alonga portion of its length from cicatrisation of an ulcerated-surface, produced by irritation, it is not necessary thatPascal material should get into the appendix beyond thestricture, since the accumulation of the secretion of thedistal portion of its mucous lining is quite sufficient to-set up recurrent attacks of inflammation in the part. Theseattacks of inflammation of the appendix appear to me toform an interesting example of the manner in which theeffect is so readily mistaken for the cause. The observer hasbecome aware of the fact that a considerable quantity of lym-phatic gland structure exists in and about the distal portionof the appendix, and that these attacks of inflammation aremore common during young life when such lymphoid tissue ismost abundant, and from these premises, obviously verydoubtful, he appears to argue that inflammation of thislymphatic tissue is a primary condition and a cause of thetrouble. Others, again, find that patients suffering fromrheumatism are liable like other people to these attacks, andthey speak of a rheumatic appendicitis. I will not delay tocriticise these statements since your common sense will, Iam sure, readily afford more simple explanations of theseassociations. That the presence of soft fsecal matter in anappendix which is normal need cause no symptoms4s familiar to all operating surgeons. The expulsionof a piece of hard fasces which has found itsway into the appendix is usually a matter of considerablemechanical difficulty even in the normal appendix, and the

reason for this is obvious, since there is nothing but themuscular action of its walls to expel it. The process ofexpulsion is expressed clinically by symptoms we will con-sider shortly. That the difficulty in expelling its contents ismuch exaggerated by a loaded condition of the cascum isapparent, and that people who are habitually constipated aremore liable to attacks of appendical colic than those in whomthe intestines act regularly and the fasces are of normalconsistence is a matter of common knowledge and readilyintelligible. In an appendix whose mechanics have beenimpaired by anchoring of a portion of it or of its wholelength the difficulty of expelling solid or even liquid materialfrom its interior is enormously exaggerated.* in consequence of the presence in an appendix of materialwhich it cannot rapidly expel it may become inflamed. Thismay not exceed a transient inflammation of the mucousmembrane, or it may be so violent that the hugely swollenappendix may become gangrenous. Associated with aninflammation of any degree there is a variable amount of

peritonitis, the character of which differs within widelimits. In some cases there is merely a little plasticlymph which for a few hours or weeks attaches the

appendix to the adjacent viscera; in others there isa large quantity of serous fluid, which diffuses itself

through the peritoneal cavity; and, again, in othersthere is a variable amount of creamy pus distributedin the same uniform manner. The difference in the characterof the peritonitis varies presumably with the virulence andnumber of organisms which have found their way through theinflamed wall of the appendix. Such an intense peritonitisas that last described may result without any perforation ofan abscess in the wall of the appendix or of any localisedcollection about it, and the removal of the inflamed appendixand consequently of the supply of organisms may be followedby a pretty rapid subsidence of a so-called suppurativeperitonitis. This was very well illustrated by a case which Ireported in the Transactions of the Clinical Society for 1894in which pus was uniformly distributed through a highly in-flamed peritoneal cavity, the appendix being swollen as thickas one’s thumb. The appendix was removed and the abdo-men closed, no attempt being made to remove the pus, andrecovery was perfect and complete. I believe that the pre-sence of pus in the peritoneal cavity in cases of recoverableperitonitis is much more common than is usually suspected,but is not recognised, since the physician knows very little ofthe conditions as they exist, but only as they will appearwhen the disease has reached such a stage that death ensues.It is in this manner that surgery has exposed phases ofdisease that were previously quite unknown or more usuallywere utterly wrongly described in the most confident manner.I would point out to you as a most important point that it isonly in those cases where matting ensues that a tumouror, to be more accurate, a feeling of resistance, is to be felt.In the case of serous or purulent inflammation of the peri-toneal cavity no mass is to be felt and the appendix cannotbe detected, although it be much enlarged, because of therigidity of the abdominal wall or of the distension of theintestines over it with gas. How often have I seen valuabletime lost because under these conditions the medicalattendant was unable to feel any hard mass in the right iliacfossa. You, gentlemen, only require to have this fact clearlyexplained and pointed out to you to make it impossible foryou to be guilty of such an error of judgment and of observa-tion, the result of which might be fraught with disaster toyour unfortunate patient. There is no other class of case whichwill make a greater demand on your knowledge, reasoningcapacity, determination, and skill than will these cases ofperitonitis resulting from inflammation of the appendixwhere no plastic process exists, and upon you the life ofyour patient hangs. I need hardly point out to you that Ido not refer here to such violent cases of acute suppurativeperitonitis as result from a perforation of the appendix itselfor the rupture into the general peritoneal cavity of a foulabscess already in communication with this organ. Theserun a very different course.

Owing to the presence of irritating material which cannotbe rapidly extruded the mucous membrane may be en-

croached on by organisms to a considerable extent, sothat ulceration results, and this may be followed later bystricture of one or more portions or of the entire lumenof the tube, or the infective process may determine theformation of an abscess in the wall probably originating inthe lymphatic tissue or so-called solitary glands, and thisabscess may burst into the cavity of the bowel or externally

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into the general peritoneal cavity. In most cases, however,some adhesions form between the appendix and the adjacentbowel, so that a localised abscess results. This usuallyterminates by bursting into the bowel, but may, as youknow, rupture into the general peritoneal cavity, into anotherviscus, or externally. When they burst into the appendixan anchoring of the appendix at the point indicates its posi-tion, the rest of the process usually becoming freed later bythe inflammation subsiding and the adhesions disappearing.I do not propose at the present to deal with the clinicalsymptoms of the more severe varieties of appendicitis, butwill discuss those which are not so dangerous to life, as theyare productive of discomfort and misery to the patient. Itis a most unfortunate thing for the patient that the vermi-form appendix has the uterine appendages as such nearneighbours. I have found that a very large proportion offemale patients suffering from appendicitis have sufferedmuch from this unfortunate propinquity, both financially andfrom delay, consequent on the fact that pessaries, bromides,oophorectomy, and ergot have no influence whatever upon thevermiform appendix, however ;useful they are under suitablecircumstances.By far the most frequent and at the same time most

rarely recognised variety of appendicitis is that in whichthe clinical symptoms represent the Effort on the partof a normal appendix to extrude its contents into the cascum.The explanation of this is due to the fact that these caseshave come but comparatively recently under the care of thesurgeon. The symptoms presented by the patient are mostvariable as regard pam, tenderness, sickness, constipation,diarrhoea, &c., and in doubtful cases, and even in the largemajority of cases, the only means by which they can be

recognised with certainty is by finding an appendixwhich is distinctly painful on pressure. This is theonly characteristic and distinguishing feature of the icondition, but you must remember that it is one ofwhich the pntient is but rarely cognizant till hisattention has been directed to it by careful manipulation.In the earlier days of operative interference in these casesgreat stress was laid upon a certain fixed point in a linejoining the anterior superior spinous process with theumbilicus as indicating the position of the appendix. This,however, you will find of very little value in these conditionsowing to the very varying position of the appendix. Cer-tainly in a large proportion of cases the most tender spotwill correspond to a point somewhere between the internaland external abdominal rings or just above that level.The sequence of symptoms usually presented in a well-marked case consists in a feeling of discomfort in thestomach which those who have had previous expe-rience readily recognise as indicating the onset of an

attack. The discomfort is succeeded after a time by pain,which is at first slight and intermittent, then becominggriping and more and more intense, spreading all over theabdomen, but more marked below. Vomiting may accompanythese attacks. After the severe pain subsides the wholeabdomen is tender on pressure and if palpated a spot corre-sponding to the position of the appendix is very painful whenpressed on. In many cases during the attack it is possible tofeel and define the appendix, which is usually very distinctlyenlarged. After the attack digestion is often very much

impaired, the appetite being small and the bowels irregularand loose, sometimes not regaining their normal character forweeks. Though this description refers to a typical attack, yeta very large proportion of cases give no such clear history.For instance, vomiting and diarrhoea may be the onlysymptoms in some cases, in others gastric discomfort, inothers there may also be frequent micturition, distension ofthe bladder being associated with discomfort or pain. Inthese cases the appendix has probably dropped into the truepelvis and comes into relationship with the urinary bladder.These symptoms are usually more marked if they come onduring the menstrual period. Very great difficulty is

experienced in distinguishing those symptoms pro-duced by the irritation of a normal appendix fromthose due to distension of an appendix which hasbeen anchored by inflammation or whose lumen hasbeen constricted by cicatrisation of an ulcered surface.As a matter of fact, the symptoms are similar in both cases,though usually much more severe in the case of the damagedviscus. In the latter it is possible not uncommonly to makeout the irregular form of the appendix or to detect itsfixation to adjacent structures. Besides this, I think thatusually even between attacks one can separate these cases by

the fact that when the appendix is normal no pain is er-

perienced by the patient when firm pressure is made on it,while in the deformed and adherent tube, besides its being’possible to detect its form, pain is complained of when it isforcibly compressed. The practical outcome of the pos-sibility of distinguishing these conditions is that in theformer the careful regulation of the intestinal functionsby means of strychnia, belladonna, and aloes serves to pre-vent the attacks with a fair amount of certainty, while in thelattar such treatment, though occasionally uf service, toe.often has no effect whatever on the attacks. The mecbanica)reason for this is quite obvious. There is one great satisfac-tion-namely, that if the attacks are sufficiently painful orincapacitating to demand operative interference it can btperformed with complete safety between the attacks providedthat in very difficult cases the surgeon recogniseswhen it is wise to hold his hand. I have operatedon a large number of cases without having experienceda single bad result. In three I failed to remove theappendix. In one of these, a young man with a

very fat abdominal wall and much fat in the viscera, therewere such violent expiratory efforts that I was very pleasedto be able to close the abdomen again without removing oreven finding the appendix. In two others the adhesionswere most extensive and general, yet at the same time, withmy present experience, I think I would have succeeded in.removing them. I would advise you to take much care andtrouble in bringing the several planes of abdominal muscleand tendon accurately together, for I have seen patientowho have been operated on by surgeons, who I imaginecannot have taken these precautions, presenting large hernial,protrusions in the abdominal wall by no means creditable to,the average surgery of the present day.As to the treatment of appendicitis the following rule

may be of service. In the mild forms the regulation of thefunctions of the intestines by means of the suitable combina-tion of drugs already indicated is sufficient to relieve the

patient of further recurrences. If the attack is very painfugive morphia to allay the pain, keep the patient perfectlyquiet, and if you suspect any loading of the large bowel give alarge enema. If the pain, vomiting, and general disturbaince.are great give morphia in sufficient quantity to keep thepatient thoroughly under its influence. If there is mattingof the intestines about the appendix there is very rarelycause for real anxiety, since perforation is unusual in-these cases, and if an abscess of considerable size formsit will spread in the direction of, and involve, the abdominalwall. The treatment of these fluid accumulations is a matter-of vital importance to the patient. Unless symptoms arepressing be in no hurry to open them, knowing that everrwhen of considerable size they will frequently subside,owing to a loss of virulence or death of the bacilli of the’colon which produce them. Do not, as is too often done,.treat these collections when opened with other than the’most scrupulous aseptic precautions, ensuring the non-

entry of any other organisms other than those present..My practice is, if I am obliged, to evacuate as much pus’as possible, packing freely with sterile iodoform gauze,having previously passed sutures through the severa?muscular or aponeurotic planes. This I do because of’the difficulty one may experience in recognising themlater and the resulting imperfect approximation oftheir edges with an unsatisfactory abdominal wall as a con-sequence. Within twenty-four hours, or after as short aninterval as possible, I bring the edges of the wound accu-rately together. The great importance of keeping the so-called abscess free from other organisms is that the bacillusof the colon appears to exert no deleterious influence what-ever upon the healing of these wounds-in fact, they usuallybehave as perfectly sterile wounds. Surgeons too oftenimagine that because the fluid contained in these abscesses-presents a fascal odour that they need take no precautionswhatever and are satisfied to apply dressings solely with the-object of collecting discharge. Treated in this way suppura-tion may be prolonged for a sufficiently long period todamage irretrievably the health, even if it does not destroythe life, of the patient.The cases which, as I have already indicated, make the-

greatest demand on the surgeon’s ability are those in whichthe peritonitis is serous or purulent and there are few or no’adhesions. In these when the surgeon is in doubt he hadbetter interfere and remove the appendix, the source

from which organisms continue t3 be distributed throughthe peritoneal cavity. During the progress of some of

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’he cases in which an abscess has formed in con-

aexion with the appendix, and yet while it is prettyobvious that the anterior abdominal wall has not becomeattached having felt great anxiety that the abscess

might burst into the general cavity, I have opened theabdomen, found a quantity of serous or perhaps sero purulentfluid free and a mass of matted bowel in the iliac fossa. Insuch cases I have wrapped the matted mass up in sterilisediodoform gauze and differentiated the several layers of theabdominal wall with sutures. This gauze I removed withina variable time. In some cases on its removal pus escapesfrom within its folds which have shut off the general peri-toneal cavity by their presence, while in most the mass hassubsided considerably in bulk. In the latter case the openingin the abdominal wall was closed at once. I need hardlypoint out the safety of this measure A surgeon may readilyfaesitate to expose the patient to the ribk of opening anappendical abscess, removing the appendix and drainingthrough healthy peritoneum, especially if the assistance athis command is not of the best ; but these means I haveindicated secure the patient’s life at a minimum of risk fromoperative interference.

There is little to say about the treatment of such cases of;intense peritonitis as result from the rupture of an abscesssin communication with the interior of the appendix into the.general peritoneal cavity or by the establishment of a direct’communication of the interior of the appendix with thegeneral cavity except that interference to be of anyi-ervice must be very prompt. I am much opposed to

lushing the peritoneum in these as in all other similarcondition, but prefer to wipe the parts thoroughlyand then, if there is not much distension of theintestines, to wrap them up in a quantity of sterile

&bgr;’l.m:e. This causes no serious damage to the peritonealcovering and can be removed readily later. It is verytimporta-nt that plain sterile gauze should be used for this

purple and not a gauze containing any irritating germicidalj;Ub8tane. In my experience a large number of these con-,ditions are brought about by violence. The appendix isanchored by a recent or old abscess to the posterior wall ofrtha abdomen and the traction exerted on it by the sudden.and violent displacement of viscera results in the generalinfection of the peritoneal cavity. I

TWO CASES OF INTESTINAL RESECTIONFOR CANCER AND ONE CASE OF

" INTESTINAL EXCLUSION."1

BY C. B. KEETLEY, F.R.G.S. ENG.,SURGEON TO THE WEST LONDON HOSPITAL.

’CASE 1. Intestinal exclusion in a case in which an artificial.anus opened into a coil (If small intestine, which, in turn, com-.enllniaated by a fi.Btulous track with the rectum.-I saw a

young woman aged seventeen, a patient of the late Mr.l3ruce Payne, on Jan. 25th, 1894. Her illness began ayear previously. Pus had been escaping per anum and thetemperature had been hectic all the time. The illness hadfollowed exposure of the feet and legs to cold and wet. On

’examination I found that the bypogastrium was the seatof an abscess on the point of bunting, the skin beingblue and thin, and an are’t of cedema spreadingwidely around it. With.Mr Payee’s help and that ofDr. Trethowan, I incised the parts freely and followed

sp the suppurating tracks wherever they had burrowedboth in the abdominal wall and p ]vie cavity. The!pus was fc,l and one track led into the rectum.The uterus and its appendages were held stiffly in’one position, the uterus over to the right, by inflammatory’thickening in the broad ligament The right Fallopian tube’felt hard, thick, and convoluted, but the ovaries seemedinormal and not adtierent peritoneally. A minutely carefulprocess of scraping and sponging was gone through, re-

tiring free incisions, two of which divided the recti overthe pubes. My experience is that mere drainage is all butuseless in such cases. The peritoneal cavity was opened,but not until the cleansing process was finished. It could

1 A paper read at a meeting of the Medical Society of London onOct. 28th, 1895.

not be closed again as the hypogastric parietal peiitoneumand sub-peritoneal tissue were too soft to hold sutures.Drains were arranged, sutures passed through the skin,aponeuroses, and recti. An aperture still remained, leadinginto the peritoneal cavity, whish was closed with iodoformgauze. The wound was dressed night and day on thefollowing day (Fiiday) and again on the Saturday morn-ing by myself. A fortnight afterwards I saw the patientagain. Her general condition wag very good,’but a regularfalse anus leading into the small intestine was developed atthe bottom of the wound. I recommended the recesses ofthe wound to be washed out with iodine water and once aweek with nitrate of silver (5 gr. to 1 oz ) and an occa-si ’nal injection of iodoform in oil. When I next sawthis patient, nine months afterwards, the fsecal fistula

leading into the small intestine was large enough to admita hen’s egg with ease, and from it another fistulaabout three inches long led straight into the rectum. Itwould be wearisome to relate how I tried to remedy things byplastic operations with very little benefit. There was no

difficulty in keeping the temperature down and the generalcondition good in a nursing home in London, but in spite ofthe sea air the patient always had some degree of hectic athome. though nothing like what had sapped her healthbefore the original operation. Finally on April 17th, 1895,the following operation of intestinal exclusion was per-formed. Mr. Lloyd administered the anaesthetic and Mr.Scott Elliot and Mr. H. Wharry assisted me. Measureswere taken to keep the patient warm. The ileo-rectalfistula was thoroughly cleansed. The incision was semi-circular and transverse through the recti. She was nowplaced in a semi-Trendelenberg’s position. I separated theintestinal and mesenteric adhesions to the abdominal wallnear to the fascal fistula, care being taken not to tear thoseimmediately around the fistula, half an hour being thusoccupied. The condition then existing is shown in theannexed diagram. Four constricting rubber tubes were

Diagram illustrating Case 1. By mistake it repreents a viewfrom below, not from above, as the intestine was actuallyôeen during operation. In other words, the coil A’ A wasto the left side of the abdomen.

l applied at A. A’, B, B’ respectively, and a short longitudinall slit made at D. Transverse division at C and C’ permitted- suturing of C to C’ to be performed by Maunsell’s method-: i.e., after both ends were intersuscepted through the segment

C A and out at the slit D. Silkworm gut sutures were used.The excluded ends were then sewn up. The part E was

l drawn inside out through the artificial anus and then

I sewed up. On returning it, however, I could not satisfy. myself that it was securely closed, so I did this part of,

the proceedings over again. The same half-closed appearance; again presented itself, but I then found it was only apparent., The part F could not be turned inside out and was closed, from the peritoneal aspect. No drainage was used. The

l patient’s recovery was interrupted by the formation of a

I temporary faecal fistula which burst out a fortnight after the- operation and was only persuaded to close after long treat-L

ment by injections of vauous kinds, by the electro-cautery,t and by a starvation diet in which the patient was partly fed

by peptonised food placed in the blind intestinal pouch,which still exists and discharges a little mucus or muco-

, pus-very little-above the pubes. It is admirably adapted1 for physiological experiment. Ultimately I intend to close

it by some plastic procedure. The intestino-rectal fistula