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ORATION IN SURGERY

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Original Articles

4. The surgicalmente aplied require cer

tain modifications to meet the conditions present. ACUTE GANGRENOUS OR PERFORAT

According to anatomists, the appendix is found

in the retrocecal position in 20 per cent in indiIVE AND SUPPURATIVE RETRO

viduals. In the general or normal type, the appenCECAL APPENDICITIS.*

dix arising from the base of the cecum passes

more or less downward and toward the midline JABEZ N. JACKSON, A. M., M. D., É. A. C. S. of the body. It communicates thus with the genKANSAS CITY, MO.

eral peritoneal cavity. The designation retro

cecal, on the other hand, is given to those apI have chosen for my discussion before you this

pendices which from the base of the cecum pass morning the acute perforative or gangrenous and

upwards and backwards to the outer side of or suppurative affections of the appendix, and my

behind the cecum and ascending colon. This remarks are confined to this generally distinctive type is therefore confined to the lateral peritoneal type. To this type Deaver is said, some years fossa, outside the colon, and extending upward ago, to have given the designation, "The bad ap

toward the kidney and liver. pendix.” Our early experience fully confirmed

Anatomical Varieties: In our experience we this designation through a distressingly high have observed four distinct anatomical varieties mortality rate. The observation, however, of cer

of the retrocecal appendix: tain facts in the history of these cases, with cer

1. The simplest form presents the usual mestain changes in our surgical technique, have given entery and only differs from the normal in its us such satisfactory improvement in our results that we deem them possibly worthy of considera- position and course.

2. A second variety passes upward, outside tion.

the colon beneath the peritoneum of the lateral The retrocecal appendix is of particular inter

iliac or lumbar fossae. It is without mesentery est for several reasons :

and is often in fact really retroperitoneal, its an1. Because this anatomical position of the

terior half alone invested by peritoneum. Curiappendix is more common than usually appre- ously, however, it is usually free at its tip above ciated, and in this position, owing to certain ana

and there completely invested with peritoneum. tomical features, seem particularly prone to in

3. The third type passes upward along the fections of the type under discussion.

lateral wall of the cecum and colon, and its peri2. In this position the routes of extension of infection and the ensuing pathologic sequellae toneal covering is that of the colon wall. Its half infection and the ensuing pathologic sequellae lying in contact with the gut wall likewise has no are quite different from those in the more normal

peritoneal investment. In this type we can readanatomic position. 3. With these changed pathologic extensions ily see how an abscess may rupture into the gut

and thus spontaneously evacuate and cure itself. the symptoms are so different that to one not

4. Finally, there is a fourth variety, quite familiar or carefully observant the diagnosis may

In this instance the appendix passes upbe overlooked or mistaken, with consequent un

ward directly beneath the cecum and ascending warranted delay or neglect in the application of

colon between the layers of the meso-colon and proper surgical measures; and

is thus a true retroperitoneal appendix. *Read at the Sixty-ninth Annual Meeting of the Illinois

Pathological Sequence: Practically speaking, State Medical Society at Peoria, May 22, 1919.

rare.

there may be roughly called two stages in the through his draining abscess. A second case of pathologic development of acute appendicitis: draininge through the bronchus was thereby ap

1. The stage in which the infection is con- parently relieved and finally recovered. fined to the appendix itself.

Besides these peritoneal extensions, we have 2. The stage in which the infection breaks also to consider the extensions through the celluthrough the gut wall and is extended to sur- lar tissues. This route of extension may occur rounding structures, the peritoneum generally, either directly from a perforation of the retroor in certain instances the cellular tissues, or in peritoneal portion of the appendix in either type rarer instances into the blood stream, particu- two or type four, or secondly from adhesion larly the veins.

and necrosis with perforation of posterior parietal In the first stage, the course of the disease is peritoneum. We have had two of these cases in the same regardless of the position of the appen- which a bulging abscess presented behind above dix. In this stage an excision of the appendix the crest of the ileum and required simple inciremoves the entire focus of disease with an ex- sion and drainage with recovery. One other case pected quick recovery, with practically no mor- was observed in which the infection penetrated tality. Hence the urgency of early diagnosis and the posterior muscular parieties, reaching the subearly operation.

cutaneous fatty tissues, with extensive cellulitis In the second stage come changes, particularly and abscess beneath the skin of the whole lumbar in the ensuing peritonitis and its extensions. In region and extended down over the buttocks and the normal type of appendix the general peri- in the thigh, almost to the knee. This case died toneum is more or less exposed and its diffusion of septicemia, despite multiple incisions and is the element of chief importance.

drains. In the retrocecal appendix the peritonitis is One other case of retroperitoneal abscess we primarily extended to the lateral or lumbar peri- observed which was opened by a free lumbar toneal fossa and is usually early confined by adhe

incision. The perinephritic fat was destroyed and sions to this space outside the colon, which rather the kidney literally floated out of the wound. effectually shuts it off from the general peri- This case was operated upon in the country. toneum on the inner side of the colon. Its ex

Later the patient died and autopsy was secured. tension is henceforth upward to the outside of This revealed a further retroperitoneal extension the colon toward the kidney and the under and

across the spine to the opposite lumbar fossa, posterior aspect of the liver. In occasional in

which presented another large abscess. stances, when the infection reaches the hepatic In the fourth type, the extension of infection flexure of the colon, it may pass forward beneath is prone to enter the psoas muscle with more or the liver toward the gall bladder and an ensuing less extension destruction. The infection in this sub-hepatic abscess may develop. This may be location is intimately associated with the origin mistaken for an empyema of the gall bladder, of the meso-colonic veins and a septic thromboor its extension.

phlebitis occurs. Through this route the liver is More commonly the extension is upward be- reached, with resultant liver abscess, generally tween the diaphragm and the upper surface of multiple. Two such cases we have seen clinically the liver and a resultant sub-phrenic abscess. and later observed at autopsy. In each case a

a From this focus the infection may perforate the

gangrenous appendix of the fourth type was diaphragm and, involving the pleura, produce found. Likewise necrosis, in one case quite exeither a general or a localized empyema. Or in tensive and in the other localized, was found in case of adhesion of visceral and diaphragmatic the substance of the psoas muscle. In one, milpleura, the abscess may enter the lung substance lions of small infarcts with early abscesses of and produce a lung abscess, or break into a larger the liver was the sequence. In the other, more bronchus and be coughed up. In our early ex- advanced, two very large abscesses were found, perience we had one case of this type in which one in each lobe. A third case of liver abscess, a large abscess broke suddenly into a bronchus, following this sequence, we were fortunate was coughed up and, choking the opposite lung, enough to localize, find solitary, drain and cure. literally caused death by drowning the patient All of these varied complications were seen in our earlier experiences. They represent largely pearance of general tenderness on pressure and failure in early diagnosis with consequent neglect abdominal rigidity. Thus far our pathologic in operation. In part, however, they followed, processes and clinical symptoms are identical. we now believe, inefficient surgical treatment. In From now on, with the onset of the true second the past ten years these complications have not stage, our extensions and our symptoms lead to been seen.

divergence in the two types. The normal appenSymptoms and Diagnosis: In the interpreta- dix, as we have indicated, communicates rather tion of symptoms and in the correct diagnosis freely with the general peritoneum, including the of these cases we believe that again our gross di- parietal peritoneum, and in this type, owing to vision of acute appendicitis into two distinct parietal peritonitis, the general abdominal pain, stages is helpful. The symptoms in the first stage tenderness and rigidity persist until localization are distinctive and are the same regardless of occurs, when they 'are prone to settle down as the position of the appendix and only varied by watchdogs over the local focus of infection underthe intensity of the infection. These symptoms lying. may be further differentiated into (1) the con- With the retrocecal appendix, the ensuing peristitutional, or symptoms of infection in general; tonitis is usually quite restricted and is quickly and (2) the special or local symptoms which point covered in by adhesions of cecum and colon to the way to the identification of the focus of in- lateral parietal wall. The general parietal perifection.

toneum is thus not involved, except for a brief 1. The constitutional symptoms are mainly period. The signs of abdominal pain, tenderness elevation of temperature and pulse, general de- and rectus rigidity may and do therefore quickly pression and blood changes, in these acute cases, disappear. And on pressure on the anterior abrepresented by the leucocyte counte. They are dominal wall over the region of the appendix we chiefly important (a) in proving that we have will find little or no rigidity and little or no tenan infection process to deal with and not, for ex- derness under pressure. Even deep pressure may ample, a simple colic; and (b) to indicate in elicit no tenderness. The cushion of gas in a some measure, at least, the intensity of the in- probably distended cecum prevents the pressure fection which may inform or warn us of the reaching the infected and inflamed peritoneum probable course and termination.

sheltered beneath its protection. 2. The local symptoms call for close observa- When the appendix communicates with the tions in the diagnosis of the retrocecal or other general peritoneum, we can ordinarily later find, position of the appendix. The initial local symp- when the peritonitis localizes, a tumor, partly the toms of any acute appendicitis are gastric and expressions of a local abscess forming, sometimes epigastric as a rule. Rather sudden onset of the result of infiltration and edematous thickenrather severe pain usually referred to the stomach ing of all the structures involved in the localizaor at least the upper abdominal region; more or tion-parietal peritoneum, intestines, omentum, less vomiting, sometimes persistent and severe. etc. These, with the infectious symptoms mentioned, These similar processes which occur about the constitute the characteristic onset of acute ap- retrocecal appendix, however, are masked largely pendicitis and may be the only symptoms of the by the overlying colon. Sometimes a suggestion first stage.

of fullness can be detected on careful palpations The second stage, as we have noted, marks par- well outside the colon and toward the back. Someticularly the extension to the peritoneum and times nothing can be felt even under anesthesia. consequent peritonitis. With the approach of If, however, one will make deep pressure with the this stage there is commonly a group of symptoms finger above the crest of the ileum posteriorly indicative of peritoneal ifritation or congestion and in the lumbar fossa he may elicit a very diswhich precedes actual peritoneal involvement and tinct, often severe, tenderness, totally unsuspected infection. This is marked by a more or less wide- by patient before search. This posterior tenderspread pain in the lower half of the abdomen, ness on pressure is a valuable diagnostic sign with possibly some lessening of epigastric pain when taken in connection with a proper anteand gastric symptoms. With this pain and indi

cedent history. cative of parietal peritoneal reaction is the ap- In the absence noted or in the rapid subaidence

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of the commoner symptoms, which are really sion to give us the best access to these appendices. those of peritonitis, the medical man is ofttimes Usually it will require extension by a free incimuch upset in his diagnosis. The signs of gen- sion of the muscles backward to give adequate eral infection (fever, leucocytosis, and pulse dis- exposure, particularly if the appendix runs up turbance) will still persist, but now often only high toward the liver. The straight outer rectus confuse the diagnosis. · How often we have had incision throws us too far to the inside of these a doctor bring in a case with about the following appendices and exposes the general peritoneum remark: "Doctor, when I first saw this patient I to infection. After free incision we find ourselves thought he had appendicitis. But in a couple of in the free peritoneal cavity with no adhesions days all the symptoms of appendicitis were gone.

to the inner side. Before attempting to enter the His fever kept up, however, and I then thought abscess the general cavity is thoroughly prohe probably had typhoid fever. However, the tected by hot moist gauze packs placed over to course has not been just that of typhoid fever, the inner side of the colon throughout the length and now I do not know just what is the matter, of the wound. Then with the index finger so I have brought him to you.”

hugging the lateral parietal well we bore down The proper diagnosis will require (1) an accu- between it and the colon or cecum and thus reach rate detailed elicitation of the symptoms of the readily the abscess. Mopping out the pus cleanly first twenty-four to forty-eight hours, which are all adhesions to the lateral parietal wall are freely of paramount importance; (2) an appreciation separated and the colon is thus mobilized from of the fact that the later signs of appendicitis the lower end of the cecum upward as far as are chiefly those of peritonitis, and that in the necessary. We are thus able to see pretty well the retrocecal appendix this peritonitis is confined field of involvement. In all cases we aim to get to the limited space outside of and largely behind the appendix and remove it in toto. We can the cecum and colon; (3) the evidence of con- usually find some normal appendicular structure tinued infection; and (4) the slight stiffness either at the base or at the tip, from which known and the distinct tenderness on pressure above structure we begin our enucleation. the crest of the ileum in the lumbar region. In only a few instances is there complete

Treatment: The treatment of retrocecal ap- gangrene without recognizable structure of an pendicitis as of appendicitis anywhere is surgical. appendix left. Sometimes the surrounding tisEarly diagnosis and early operation is of course sues are so infiltrated, thick and hard that recogindicated here as elsewhere. But we are not in nition of the appendix is difficult. But somewhere this discussion considering cases reached by the if our exposure is adequate, we will find recogsurgeon at this happy stage. We are here con- nizable ground for å start. Vessels are clamped cerned only with those which have passed on to as developed. When the appendix runs along gangrene or perforation with attendant suppura- the colon wall (as in Type 3) great care is tion and abscess formation. As a rule these as required to avoid a tear into the gut. others are operated upon as soon as they come After freeiņg the remnants of the appendix under observation. There is not here, however, we endeavor to find a healthy base for ligation, the same acute danger as where general peri- in order to obviate subsequent fistula. For tonitis is a threat. In certain types therefore similar reasons the raw area and the stump are we take time to load the patient up with glucose covered as completely as possible by sutures exand bicarbonate of soda, by proctoclysis and hypo- tending into normal peritoneum on either side. dermoclysis to develop an alkaline reserve, wash The colon will tolerate considerable infolding out the stomach (by lavage), and colon (with and with experience it is rather remarkable how enemata alone), to get rid of gas and lessen the complete a peritoneal, covering of extensive raw dangers of post-operative intestinal paresis. We surfaces can be obtained. thus may convert an apparently very sick patient The next step constitutes the one which in our presenting great surgical risks into one able to experience has spelled the difference between meet his ordeal readily. This delay does not high and low mortality. This is that of proper mean more, as a rule, than twenty-four hours. drainage. With the body in the horizontal posi

Incision: We have found the McBurney inci- tion there is quite a basin above the crest of the

ileum in the lumbar fossa. A drain passed the appendix, which is at the crest of the drainsimply down to the base of the appendix does age divide between the lumbar basin behind and not reach and drain this basin. In one of our the pelvic basin below, it is well to recognize that early cases, drained through the anterior wound some of the leak may spread also into the pelvis. in the usual way and drained apparently well, In this instance, after cleaning out the pus in we found our patient still maintaining a septic the pelvis the cigarette drain is carried down to course. After a morning dressing with suppos- the floor of the pelvis. The remainder of the edly careful cleaning under irrigation, in reach- incision down to the drain is then sutured in ing under the loin to lift the patient for removal layers—muscle aponeurosis and skin. of a Kelly pad we, to our surprise, pressed out Finally it is of value to remember that during thus over a half pint of pus retained behind in our operative manipulations the parietal wound this basin. This led us to make free lumbar stab has been exposed to considerable infection and and introduce a large rubber tube of one inch

that necrosis of fat and fascia are frequent. To diameter for drainage of this area.

lessen the extension of such infections and thus With the finger, through the anterior incision, to save the integrity of our abdominal wall, we we can locate this lowest spot above the crest order the immediate institution of continuous of the ilium and then stab through a counter hot fomentations applied directly to the wound. wound adequate for the tube drain. With a pair Moist heat increases exudation, lessens absorption of forceps passed from behind into the cavity and enables us to lessen and in some instances and out through the anterior wound, the large to entirely avoid extending infection and fascial tube is seized and drawn through until its inner

necrosis. It thus shortens convalescence and end is left just above flush with the peritoneum lessens liability to weak walls and subsequent of the fossa. It should not project too far inside hernia. lest it press against the gut and by pressure necrosis induce a fistula. After placing drain

After placing drain TEMPERATURE VARIATIONS IN properly it is fixed by a suture of silkworm gut. INFANCY AND EARLY CHILDHOOD* This simple experient revolutionized our results.

ORATION IN MEDICINE Many of the disasters mentioned earlier in our discussion had followed operation as then done

ISAAC A. ABT, M. D. and our mortality had been over twenty-five per

CHICAGO cent. Since the routine introduction of this Temperature observations in newly born and method of drainage it has been reduced to almost young infants have not only scientific interest nothing. In looking up the results in one of our but have an important clinical bearing. The services for the last five years we find in this

proper interpretation of the wide temperature one series alone sixty-seven cases of this type fluctuations in infants is of fundamental imwith but one death. This death was from ne

portance but, like other fundamental phenomena, phritis in a case brought in from the country

is rarely emphasized. The peculiar levels and and operated upon at once to accommodate the

irregular temperature curves in young infants family doctor who wanted to get home on the

should be recognized. Changes in temperature next train. This is the only death we can recall

in infants have not necessarily the same signifiin our five years consecutive experience. Most

cance as in adults. Sudden high temperatures of our disasters were before the knowledge or

in newly born infants are of frequent occurrence. use of the Fowler position. Perhaps this position

It is important that we have some standard alone might improve ordinary results, but we

limits in order to differentiate between normal do not believe so to the extent we have secured

fluctuations of the temperature and those indiby such drainage with the ordinary recumbent

cating pathologic processes. position. In is the point in technique therefore

It would scarcely seem of sufficient importance on which we wish to lay stress.

to discuss the technique of taking the temperaAfter installation of lumbar tubular drain,

ture. Though the older clinicians took the tema cigarette drain is introduced at the lower end

perature from the groin or axilla, the rectal of the incision down near the apex of the cecum.

*Read at the Sixty-ninth Annual Meeting of the Illinois State When the perforation takes place at the base of

Medical Society, at Peoria, May 21, 1919.

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