Case in which the ccuiri was found well toward the median line; the ap pendix was lying directly across the abdominal cavity, bound to the omen tum in the left iliac fossa. M. M. Franklin (Univ. Med. Mag., Oct., '97).
If the appendix contain a concretion or foreign body, or is enlarged, perfo rated, or otherwise abnormal, it should be tied close to the cwcum, then cut off below the ligature. It is sometimes found detached and necrotic.
If there is a circumscribed abscess, it is poor surgery to insist, in every case and at every period, upon finding and taking away the appendix in the face of all obstacles. In many cases of circum scribed abscess, and especially in those in which the appendix is bound down by adhesions in the depth of the wound, the surgeon should be content with evacuation, irrigation, drainage, and packing with iodoform gauze. Persist ent search for the appendix and at tempts at its removal in these cases are attended with such danger of opening the peritoneal cavity that they are not to be recommended. William White.) When circumscribed peritonitis and abscess exist the indication is clearly to drain. To persist in breaking up ad hesions for the sake of removing the appendix is not wise. Richardson (Amer. Jour. Med. Sciences, Jan., '94).
The appendix should be removed when there is no pus; when an endoappen dicular abscess is present; as a rule, when there is a periappendicular abscess requiring drainage through peritoneal cavity; and when there is a general peri tonitis without adhesions. Porter (Med. News, Sept. 14, '95).
There are sonic eases, not few in num ber, in which the appendix is so deeply imbedded in the wall of the abscess, or so difficult to define at all, that to in sist upon its discovery and complete removal would be to incur quite sin justifiable risk. One had better be con tent with properly evacuating, cleansing, and packing the cavity, leaving the appendix or its remnant to be disposed of by its obliteration in the wound healing, or by its removal at a later and more favorable time through a second operation. McBurney (Univ. Med. Mag.. Mar., '96).
It has been my practice to carefully evacuate and cleanse by dry sponging with sterilized or iodoform gauze the pus-cavity; then to disinfect its walls with a bichloride solution, 1 to 5000; and then to search for and remove the appendix in ease it be readily found and easily separated from the adhesions. In general, I have found this feasible in cases operated on up to the seventh or tenth day. In cases operated on at a later date, of those where the abscess is distinctly circumscribed with firm walls and containing several ounces of pus, I have not attempted to remove the appendix. Bull (Univ. Med. Mag.,
Mar., '96).
It has been my habit for years in eases of acute appendicitis with exten sive suppuration to simply incise, dis infect, and drain the abscess, unless the diseased appendix could be removed without any additional risk. I have seen a number of such cases recover per manently without any additional sur gical interference. I regard persistent search for the appendix in such cases hazardous, as it often results in opening of the free peritoneal cavity and fatal septic peritonitis. Senn (Univ. Med. Mag., Mar., '96).
In cases of appendicitis in which the appendix is found to be densely ad herent. or when it opens into an abscess, or when there exists a more or less gen eral peritonitis, the operator dreads all avoidable contamination of the sur rounding tissues with any part of the appendiceal abscess, and all avoidable injury to the coats of the adherent in testine. When the appendix is diseased and densely adherent at its tip, the best plan often is first to seek out and expose its base, which is detached and divided so as to free the appendix from the ccncum. The distal portion is now wrapped for protection in gauze, while the opening into the bowel is closed. Then the severed appendix is dissected out of its bed with much ,greater facility than was possible with both ends an chored, one to the Nueuni and one to the adhesions. This plan of procedure is especially useful in the gynecological field. In cases in which the vermiform appendix is attached to a pyosalpinx, or an ovarian or fibroid tumor, after it is severed from the bowel, it can then be enucleated with the pelvic abscess or with the tumor. When the end of the appendix enters the abscess cavity sur rounded by the adherent intestine, which cannot be stripped off with safety, after freeing the base of the ap pendix from cucum it was traced up until it entered an abscess-cavity under the ascending colon. It could not be separated from the adhesions without injuring the bowel, so the appendix was grasped with a pair of forceps, on either side, close to the abscess, and split open and followed to its lumen, as a guide, by using a grooved director and a pair of open scissors, with one blade in the ap pendix. The operator was thus enabled with certainty to enter the very middle of the abscess-cavity, and to lay it open and cleanse it without doing any clam age to the colon. H. A. Kelly (Phila. Med. Jour., from Amer. Medicine, Apr. 20, 1901).