KANSAS CITY, MO.

I have chosen for my discussion before you this morning the acute perforative or gangrenous and suppurative affections of the appendix, and my remarks are confined to this generally distinctive type. To this type Deaver is said, some years ago, to have given the designation, "The bad appendix." Our early experience fully confirmed this designation through a distressingly high mortality rate. The observation, however, of certain facts in the history of these cases, with certain changes in our surgical technique, have given us such satisfactory improvement in our results that we deem them possibly worthy of considera

tion.

The retrocecal appendix is of particular interest for several reasons:

1. Because this anatomical position of the appendix is more common than usually appre

ciated, and in this position, owing to certain anatomical features, seem particularly prone to infections of the type under discussion.

2. In this position the routes of extension of

infection and the ensuing pathologic sequellae are quite different from those in the more normal anatomic position.

3. With these changed pathologic extensions

the symptoms are so different that to one not familiar or carefully observant the diagnosis may be overlooked or mistaken, with consequent unwarranted delay or neglect in the application of proper surgical measures; and

*Read at the Sixty-ninth Annual Meeting of the Illinois State Medical Society at Peoria, May 22, 1919.

eral peritoneal cavity. The designation retro

cecal, on the other hand, is given to those appendices which from the base of the cecum pass upwards and backwards to the outer side of or behind the cecum and ascending colon. This type is therefore confined to the lateral peritoneal fossa, outside the colon, and extending upward toward the kidney and liver.

Anatomical Varieties: In our experience we have observed four distinct anatomical varieties of the retrocecal appendix:

entery and only differs from the normal in its 1. The simplest form presents the usual mesposition and course.

2. A second variety passes upward, outside the colon beneath the peritoneum of the lateral iliac or lumbar fossae. It is without mesentery and is often in fact really retroperitoneal, its anterior half alone invested by peritoneum. Curiously, however, it is usually free at its tip above and there completely invested with peritoneum.

3. The third type passes upward along the lateral wall of the cecum and colon, and its peritoneal covering is that of the colon wall. Its half

lying in contact with the gut wall likewise has no

peritoneal investment. In this type we can read

ily see how an abscess may rupture into the gut and thus spontaneously evacuate and cure itself. 4. Finally, there is a fourth variety, quite In this instance the appendix passes upward directly beneath the cecum and ascending colon between the layers of the meso-colon and is thus a true retroperitoneal appendix.

rare.

Pathological Sequence: Practically speaking,

there may be roughly called two stages in the pathologic development of acute appendicitis: 1. The stage in which the infection is confined to the appendix itself.

2. The stage in which the infection breaks through the gut wall and is extended to surrounding structures, the peritoneum generally, or in certain instances the cellular tissues, or in rarer instances into the blood stream, particularly the veins.

In the first stage, the course of the disease is the same regardless of the position of the appendix. In this stage an excision of the appendix removes the entire focus of disease with an expected quick recovery, with practically no mortality. Hence the urgency of early diagnosis and early operation.

In the second stage come changes, particularly in the ensuing peritonitis and its extensions. In the normal type of appendix the general peritoneum is more or less exposed and its diffusion is the element of chief importance.

In the retrocecal appendix the peritonitis is primarily extended to the lateral or lumbar peritoneal fossa and is usually early confined by adhesions to this space outside the colon, which rather effectually shuts it off from the general peritoneum on the inner side of the colon. Its extension is henceforth upward to the outside of the colon toward the kidney and the under and posterior aspect of the liver. In occasional instances, when the infection reaches the hepatic flexure of the colon, it may pass forward beneath the liver toward the gall bladder and an ensuing sub-hepatic abscess may develop. This may be mistaken for an empyema of the gall bladder,

or its extension.

More commonly the extension is upward between the diaphragm and the upper surface of the liver and a resultant sub-phrenic abscess. From this focus the infection may perforate the diaphragm and, involving the pleura, produce either a general or a localized empyema. Or in case of adhesion of visceral and diaphragmatic pleura, the abscess may enter the lung substance and produce a lung abscess, or break into a larger bronchus and be coughed up. In our early experience we had one case of this type in which a large abscess broke suddenly into a bronchus, was coughed up and, choking the opposite lung, literally caused death by drowning the patient

through his draining abscess. A second case of draininge through the bronchus was thereby apparently relieved and finally recovered.

Besides these peritoneal extensions, we have also to consider the extensions through the cellular tissues. This route of extension may occur either directly from a perforation of the retroperitoneal portion of the appendix in either type two or type four, or secondly from adhesion and necrosis with perforation of posterior parietal peritoneum. We have had two of these cases in which a bulging abscess presented behind above the crest of the ileum and required simple incision and drainage with recovery. One other case was observed in which the infection penetrated the posterior muscular parieties, reaching the subcutaneous fatty tissues, with extensive cellulitis and abscess beneath the skin of the whole lumbar region and extended down over the buttocks and in the thigh, almost to the knee. This case died of septicemia, despite multiple incisions and drains.

One other case of retroperitoneal abscess we observed which was opened by a free lumbar incision. The perinephritic fat was destroyed and the kidney literally floated out of the wound. This case was operated upon in the country. Later the patient died and autopsy was secured. This revealed a further retroperitoneal extension across the spine to the opposite lumbar fossa, which presented another large abscess.

In the fourth type, the extension of infection is prone to enter the psoas muscle with more or less extension destruction. The infection in this location is intimately associated with the origin. of the meso-colonic veins and a septic thrombophlebitis occurs. Through this route the liver is reached, with resultant liver abscess, generally multiple. Two such cases we have seen clinically and later observed at autopsy. In each case a gangrenous appendix of the fourth type was found. Likewise necrosis, in one case quite extensive and in the other localized, was found in the substance of the psoas muscle. In one, millions of small infarcts with early abscesses of the liver was the sequence. In the other, more advanced, two very large abscesses were found, one in each lobe. A third case of liver abscess, following this sequence, we were fortunate enough to localize, find solitary, drain and cure.

All of these varied complications were seen in

our earlier experiences. They represent largely failure in early diagnosis with consequent neglect in operation. In part, however, they followed, we now believe, inefficient surgical treatment. In the past ten years these complications have not been seen.

Symptoms and Diagnosis: In the interpretation of symptoms and in the correct diagnosis of these cases we believe that again our gross division of acute appendicitis into two distinct stages is helpful. The symptoms in the first stage are distinctive and are the same regardless of the position of the appendix and only varied by the intensity of the infection. These symptoms may be further differentiated into (1) the constitutional, or symptoms of infection in general; and (2) the special or local symptoms which point the way to the identification of the focus of infection.

1. The constitutional symptoms are mainly elevation of temperature and pulse, general depression and blood changes, in these acute cases, represented by the leucocyte counte. They are chiefly important (a) in proving that we have an infection process to deal with and not, for example, a simple colic; and (b) to indicate in some measure, at least, the intensity of the infection which may inform or warn us of the probable course and termination.

2. The local symptoms call for close observations in the diagnosis of the retrocecal or other position of the appendix. The initial local symptoms of any acute appendicitis are gastric and epigastric as a rule. Rather sudden onset of rather severe pain usually referred to the stomach or at least the upper abdominal region; more or less vomiting, sometimes persistent and severe. These, with the infectious symptoms mentioned, constitute the characteristic onset of acute appendicitis and may be the only symptoms of the first stage.

The second stage, as we have noted, marks particularly the extension to the peritoneum and consequent peritonitis. With the approach of this stage there is commonly a group of symptoms indicative of peritoneal irritation or congestion which precedes actual peritoneal involvement and infection. This is marked by a more or less widespread pain in the lower half of the abdomen, with possibly some lessening of epigastric pain and gastric symptoms. With this pain and indicative of parietal peritoneal reaction is the ap

pearance of general tenderness on pressure and abdominal rigidity. Thus far our pathologic processes and clinical symptoms are identical. From now on, with the onset of the true second stage, our extensions and our symptoms lead to divergence in the two types. The normal appendix, as we have indicated, communicates rather freely with the general peritoneum, including the parietal peritoneum, and in this type, owing to parietal peritonitis, the general abdominal pain, tenderness and rigidity persist until localization occurs, when they are prone to settle down as watchdogs over the local focus of infection underlying.

With the retrocecal appendix, the ensuing peritonitis is usually quite restricted and is quickly covered in by adhesions of cecum and colon to lateral parietal wall. The general parietal peritoneum is thus not involved, except for a brief period. The signs of abdominal pain, tenderness and rectus rigidity may and do therefore quickly disappear. And on pressure on the anterior abdominal wall over the region of the appendix we will find little or no rigidity and little or no tenderness under pressure. Even deep pressure may elicit no tenderness. The cushion of gas in a probably distended cecum prevents the pressure reaching the infected and inflamed peritoneum sheltered beneath its protection.

When the appendix communicates with the general peritoneum, we can ordinarily later find, when the peritonitis localizes, a tumor, partly the expressions of a local abscess forming, sometimes the result of infiltration and edematous thickening of all the structures involved in the localization-parietal peritoneum, intestines, omentum,

etc.

These similar processes which occur about the retrocecal appendix, however, are masked largely by the overlying colon. Sometimes a suggestion of fullness can be detected on careful palpations well outside the colon and toward the back. Sometimes nothing can be felt even under anesthesia. If, however, one will make deep pressure with the finger above the crest of the ileum posteriorly and in the lumbar fossa he may elicit a very distinct, often severe, tenderness, totally unsuspected by patient before search. This posterior tenderness on pressure is a valuable diagnostic sign when taken in connection with a proper antecedent history.

In the absence noted or in the rapid subsidence

of the commoner symptoms, which are really those of peritonitis, the medical man is ofttimes much upset in his diagnosis. The signs of general infection (fever, leucocytosis, and pulse disturbance) will still persist, but now often only confuse the diagnosis. How often we have had a doctor bring in a case with about the following remark: "Doctor, when I first saw this patient I thought he had appendicitis. But in a couple of days all the symptoms of appendicitis were gone. His fever kept up, however, and I then thought he probably had typhoid fever. However, the course has not been just that of typhoid fever, and now I do not know just what is the matter, so I have brought him to you."

The proper diagnosis will require (1) an accurate detailed elicitation of the symptoms of the first twenty-four to forty-eight hours, which are of paramount importance; (2) an appreciation of the fact that the later signs of appendicitis are chiefly those of peritonitis, and that in the retrocecal appendix this peritonitis is confined to the limited space outside of and largely behind the cecum and colon; (3) the evidence of continued infection; and (4) the slight stiffness and the distinct tenderness on pressure above the crest of the ileum in the lumbar region.

Treatment: The treatment of retrocecal appendicitis as of appendicitis anywhere is surgical. Early diagnosis and early operation is of course indicated here as elsewhere. But we are not in this discussion considering cases reached by the surgeon at this happy stage. We are here concerned only with those which have passed on to gangrene or perforation with attendant suppuration and abscess formation. As a rule these as others are operated upon as soon as they come under observation. There is not here, however, the same acute danger as where general peritonitis is a threat. In certain types therefore we take time to load the patient up with glucose and bicarbonate of soda, by proctoclysis and hypodermoclysis to develop an alkaline reserve, wash out the stomach (by lavage), and colon (with enemata alone), to get rid of gas and lessen the dangers of post-operative intestinal paresis. We thus may convert an apparently very sick patient presenting great surgical risks into one able to meet his ordeal readily. This delay does not mean more, as a rule, than twenty-four hours.

Incision: We have found the McBurney inci

sion to give us the best access to these appendices. Usually it will require extension by a free incision of the muscles backward to give adequate exposure, particularly if the appendix runs up high toward the liver. The straight outer rectus incision throws us too far to the inside of these appendices and exposes the general peritoneum to infection. After free incision we find ourselves in the free peritoneal cavity with no adhesions. to the inner side. Before attempting to enter the abscess the general cavity is thoroughly protected by hot moist gauze packs placed over to the inner side of the colon throughout the length of the wound. Then with the index finger hugging the lateral parietal well we bore down between it and the colon or cecum and thus reach readily the abscess. Mopping out the pus cleanly all adhesions to the lateral parietal wall are freely separated and the colon is thus mobilized from the lower end of the cecum upward as far as necessary. We are thus able to see pretty well the field of involvement. In all cases we aim to get the appendix and remove it in toto. We can usually find some normal appendicular structure either at the base or at the tip, from which known structure we begin our enucleation.

In only a few instances is there complete gangrene without recognizable structure of an appendix left. Sometimes the surrounding tissues are so infiltrated, thick and hard that recognition of the appendix is difficult. But somewhere if our exposure is adequate, we will find recognizable ground for a start. Vessels are clamped as developed. When the appendix runs along the colon wall (as in Type 3) great care is required to avoid a tear into the gut.

After freeing the remnants of the appendix we endeavor to find a healthy base for ligation, in order to obviate subsequent fistula. For similar reasons the raw area and the stump are covered as completely as possible by sutures extending into normal peritoneum on either side. The colon will tolerate considerable infolding and with experience it is rather remarkable how complete a peritoneal, covering of extensive raw surfaces can be obtained.

The next step constitutes the one which in our experience has spelled the difference between high and low mortality. This is that of proper drainage. With the body in the horizontal position there is quite a basin above the crest of the

ileum in the lumbar fossa. A drain passed simply down to the base of the appendix does not reach and drain this basin. In one of our early cases, drained through the anterior wound in the usual way and drained apparently well, we found our patient still maintaining a septic course. After a morning dressing with supposedly careful cleaning under irrigation, in reaching under the loin to lift the patient for removal of a Kelly pad we, to our surprise, pressed out thus over a half pint of pus retained behind in this basin. This led us to make free lumbar stab and introduce a large rubber tube of one inch diameter for drainage of this area.

With the finger, through the anterior incision, we can locate this lowest spot above the crest of the ilium and then stab through a counter wound adequate for the tube drain. With a pair of forceps passed from behind into the cavity and out through the anterior wound, the large tube is seized and drawn through until its inner end is left just above flush with the peritoneum of the fossa. It should not project too far inside lest it press against the gut and by pressure necrosis induce a fistula. After placing drain properly it is fixed by a suture of silkworm gut. This simple experient revolutionized our results. Many of the disasters mentioned earlier in our discussion had followed operation as then done and our mortality had been over twenty-five per cent.

Since the routine introduction of this method of drainage it has been reduced to almost nothing. In looking up the results in one of our services for the last five years we find in this one series alone sixty-seven cases of this type with but one death. This death was from nephritis in a case brought in from the country and operated upon at once to accommodate the family doctor who wanted to get home on the next train. This is the only death we can recall in our five years consecutive experience. Most of our disasters were before the knowledge or use of the Fowler position. Perhaps this position alone might improve ordinary results, but we do not believe so to the extent we have secured by such drainage with the ordinary recumbent position. In is the point in technique therefore on which we wish to lay stress.

After installation of lumbar tubular drain, a cigarette drain is introduced at the lower end of the incision down near the apex of the cecum. When the perforation takes place at the base of

the appendix, which is at the crest of the drainage divide between the lumbar basin behind and the pelvic basin below, it is well to recognize that some of the leak may spread also into the pelvis. In this instance, after cleaning out the pus in the pelvis the cigarette drain is carried down to the floor of the pelvis. The remainder of the incision down to the drain is then sutured in layers-muscle aponeurosis and skin.

Finally it is of value to remember that during our operative manipulations the parietal wound has been exposed to considerable infection and that necrosis of fat and fascia are frequent. To lessen the extension of such infections and thus to save the integrity of our abdominal wall, we order the immediate institution of continuous hot fomentations applied directly to the wound. Moist heat increases exudation, lessens absorption and enables us to lessen and in some instances to entirely avoid extending infection and fascial necrosis. It thus shortens convalescence and lessens liability to weak walls and subsequent hernia.

TEMPERATURE VARIATIONS IN INFANCY AND EARLY CHILDHOOD* ORATION IN MEDICINE

ISAAC A. ABT, M. D.

CHICAGO

Temperature observations in newly born and young infants have not only scientific interest but have an important clinical bearing. The proper interpretation of the wide temperature fluctuations in infants is of fundamental importance but, like other fundamental phenomena, is rarely emphasized. The peculiar levels and irregular temperature curves in young infants should be recognized. Changes in temperature in infants have not necessarily the same significance as in adults. Sudden high temperatures in newly born infants are of frequent occurrence. It is important that we have some standard

limits in order to differentiate between normal fluctuations of the temperature and those indicating pathologic processes.

It would scarcely seem of sufficient importance to discuss the technique of taking the temperature. Though the older clinicians took the temperature from the groin or axilla, the rectal

*Read at the Sixty-ninth Annual Meeting of the Illinois State Medical Society, at Peoria, May 21, 1919.