Delay in operation is a common cause of fistula. There are two types, the ex ternal and internal, the former being divided into the simple and fecal. The simple form of fistula is an external channel leading to an unhealed abscess, and corresponds to the drainage tract. This tends to heal spontaneously, and it is often due to some foreign body in the tract. A second variety of the simple fistula is where the lumen of the appen dix is in direct communication with the tract. In these cases clear mucus is dis charged, and the absence of fcal matter is due to the fact that the inflammatory process has separated the cmcum from the appendix. J. B. Deaver (Jour. Amer. Med. Assoc., July 14, 1900).
Report based on the results of personal experience in 40 cases of acute appendi citis seen during the past year. In gen eral peritonitis several cases recovered in spite of extensive involvement of the peritoneum in the inflammatory process: a feature attributed to abundant saline irrigation of the peritoneal cavity through a moderate incision without evisceration when ride-spread purulent peritonitis was present. There were S of these, 3 of which were fatal. Several of the patients who recovered not only presented the signs of severe sepsis, but the appearance of the interior of the abdomen was in several instances exceed ingly unfavorable. Had the intestines been removed from the cavity and washed and wiped, the patients would not have recovered. This method of treatment in cases of purulent peritonitis condemned. The immediate effect is a severe strain upon the lowered vitality of the parts and subsequent paresis of the bowel is frequent. A. B. Johnson (Med. Record, Nov. 3, 1900).
A large number of athletes require the removal of the appendix. If we made it a practice to operate when the trouble is first recognized, without the delay of a day or more for consultations and for therapeutical treatment, the deaths would be very few. The so-called very "conservative" man gives us the ugly abscess class of cases, and the virulent, perforative cases. Joseph Price (Jour. Amer. Med. Assoc., Nov. 24, 1900).
The ideal time to operate in appendi citis to obtain ideal results is in the stage of appendicular colic, before in flammation has taken possession of the vulnerable tissues composing this organ.
Formerly abscess-formation was re garded as the indication for operation. certainly a most unfortunate view, for then the time for an ideal operation has passed.
An abscess-cavity must heal by granulation, cicatrization, and contrac tion. In appendicular abscess of size the inner wall is formed by ad herent loops of small bowel. During contraction the calibre of the bowel is often occluded, and acute mechanical obstruction results, which, unless re lieved by immediate operation, must re sult in the death of the patient.
In personal experience at the German Hospital, where yearly from one hun dred and fifty to two hundred opera tions are performed for acute appendi citis, many of which are of the abscess type, the percentage of intestinal ob struction is comparatively small. This condition, which usually does not occur for ten days, is so feared that, upon the appearance of paroxysmal abdom inal pain, nausea, inability to pass flatus or to have the bowels moved by simple purgative medicines aided by high enemata through the rectal tube and given by hydrostatic pressure, and with the presence of slight tympany with paroxysmal pains provoked by gentle palpation of the abdominal wall, a sec tion is immediately advised. By this
practice recoveries are recorded in pa tients that otherwise would have per ished.
It is personal practice in dealing with these large abscess cases not to be con tent with the evacuation of the abscess and the removal of the appendix, but, further, to relieve the adherent coils of bowel, which, done with proper ma nipulation, skill, and disposition of sterile to guard infection of the general peritoneal eavity. and the placing of gauze drains, prevents this eompliention being more common than it otherwise would. Again, in these ab scess cases it happens frequently that, in addition to the principal focus of suppuration, there are other foci. In such instances the evacuation of the primary focus of pus does not neces sarily mean the evacuation of the sec ondary collections. This phase of treat ment is one of the most important; overlooking secondary collections figures conspicuously in the mortality of this class of cases.
Where the appendicular inflammation has involved to any degree the neighbor ing structures, particularly the great omentum, as is so commonly seen in abscess cases, it is necessary to tie off the involved portion of the omentum, winch frequently is partly or entirely gangrenous. The sooner the appendix is out, the better for the subsequent welfare of the patient. J. B. Deaver (New York Med. Jour.. Dee. 7, 1901).
The conservative treatment of ap pendicitis consists in prompt operation. The starvation method of procrastina tion is vicious and has cost many lives, because it is used as an excuse to daily with patients that should be promptly subjected to removal • of the organ. J. H. Carstens (New York sled. Jour.. Jan. IS, 1902).
Aspiration of the abscess through the abdominal wall is only indicated when it is clearly superficial; otherwise the chances of striking the abscess itself are very small and the risk may be great. Large abscesses may sometimes be evacu ated through the rectum.
There are cases in which, although, the diagnosis is not absolutely certain, it may be quite justifiable to make an exploratory incision. MacCormac (Clin ical Jour., Sept. 20, '94).
It is preferable to perform an aseptic exploratory section and be proved wrong in diagnosis than to wait until an opera tion is rendered necessary by perforation and peritonitis. Grandin (N. Y. Med. • Record, Dec. 1, '94).
Enormous appendieeal abscess incised through the rectum. Operation not al lowed by the patient, and the abscess gradually increased in size for about two weeks, his pulse being then 100 and tem perature 99.5° F. The abdomen was quite filled with a fluctuating tumor reaching within one and one-half inches of the umbilicus, filling up the right side. It extended almost to the iliac crest on the left side, simulating an enor mously distended bladder, except that the area of flatness was greater toward the flanks. A rectal examination showed that the pus had burrowed into the pel vis so as to dilate the anal sphincter. An opening was made through the rec tum, and when the sac was incised the tension was so great that the pus was thrown out for a considerable distance. Over a gallon of foetid pus was dis charged. Rapid recovery followed. Reuben Peterson (Milwaukee Sled. Jour., Apr., 1900).