The stump is either simply disinfected or the mucous membrane of cut surface cauterized with carbolic acid or cautery. The latter procedure is generally unnec essary, however. If the tissues about the base of the appendix are nearly normal, it is better to invert the stump and close it with two or three Lembert sutures.
The methods of dealing with the stump at present employed are far from perfect. After removing the appendix a contin ous Lembert suture should be run around the appendix like a purse-string. The appendix is then divided, leaving the stump never shorter than one-half inch. The stump is then invaginated,—turned "outside in," as a glove-finger,—the ap pendix end thus being inserted one-half inch inside the coecum. Dawbarn (Inter. Jour. of Surg., vol. viii, No. 8).
In whatsoever manner treated, the stump remains as an excrescence, with chances of adhesions. To eliminate these, inversion into the lumen of the large intestine of either the entire ap pendix or any part remaining attached to the caput con is recommended. Ede bohls (Amer. Jour. Med. Sciences, June, '95).
Inversion of the uncut appendix obvi ates the necessity of opening the bowels and avoids the risk of infection. Per sonally practiced in more than one hun dred cases. In performing the operation the appendix is freed from all adhesions and brought into view in the usual way. The tip of the appendix is held by an assistant, who with the thumb and fore finger of the other hand supports the colon edges below the origin of the ap pendix. The ligature is then introduced and the meso-appendix ligated, which is then severed just beyond the ligature. The appendix is then freed of its peri toneal coat. The appendix, having thus been prepared for inversion, is seized be tween the thumb and forefinger of one hand and inverted by pressing upon it with the blunt end of a needle. The mucous membrane having been inverted for some distance, the needle is substi tuted by a long probe, which easily com pletes the inversion. A single stitch is then taken, closing the opening in the bowel, which then marks the point of opening of the appendix. In a few cases in which operation is made for appendi citis inversion is impossible or so difficult as to be unwise. These cases include gangrene of the appendix and those in which there is a constriction near its base. J. F. Baldwin (Med. Record, Jan. 20, 1900).
Drainage is to be maintained until healing is shown to be taking place from the bottom of the wound. Gauze is to be used not only for the purpose, but quite as much to stimulate the adhesions between coils of intestine which sur round it and to shut off the general peri toneal cavity from the infected portion. (Halsted.) The Mikulicz drain, a bundle of lamp wicks, is an exceedingly potent means of producing drainage. Wood (N. Y. Med. Jour., May, '95).
Analysis of twelve hundred and thirty six cases of appendicitis operated on in the Massachusetts General Hospital and examined some time after operation.
Many of the cases which reported them selves as perfectly well had marked gen eral bulging of the abdominal wall on the side operated upon. Some had pro trusions of the wound, and some had hernias of which they were not aware. Intermuscular spaces could be detected in 28 per cent. of those with tightly closed wounds. These were present in S3 per cent. of those cases with wounds tightly closed and 87 per cent. of those which were left open. These intermus cular spaces result from separation of the muscles which were not brought into ap position by sutures. Drainage by gauze or by other means favors this condition, as do also transverse incisions of the muscles. The muscular and tendinous fibres should not be cut in any appendix operations if it can be avoided. When drainage is necessary, as much of the wound should be closed as possible with sutures, and the drainage removed at the earliest moment consistent with safety. Stout belts and trusses are of little value in the after-treatment of these cases, and may even do harm. The abdominal muscles, from the earliest pos sible period after the operation, should be developed with proper exercises. If hernia or marked bulging occurs, an operation for radical cure is safe and satisfactory. F. B. Harrington (Boston Med. and Surg. Jour., Aug. 3, '99).
Appendix removed while performing adjacent abdominal operations whenever it shows signs of inflammation or thick ening. Medical treatment is useless and opium should never be given. A total of 6S cases shows that, the more carefully drainage is insured, stitches in the abdominal wall omitted, and the longer the abdomen is kept open, the more successful is the result. E. Rose (Deutsche Zeit. f. Chir.. Mar., 1901).
It is important to withdraw the gauze plugs by rotary movement rather than by direct traction: it causes less pain. The patient should be revived from the shock of the operation as early as pos sible by an enema of hot coffee or whisky. (Abbe.) Two cases in which a circumscribed abscess was drained, and a sinus per sisted until the appendix was removed, some months later. Removal of the ap pendix performed through an incision parallel to one internal to the original one. The sinus, unopened, was followed down to the appendix, which was re moved after the healthy parts had been carefully walled off. All sinuses in the neighborhood of the appendix should be approached in this way. It is easier to prevent infection of the peritoneum if the cavity be freely opened so that the healthy parts may be protected and the situation of the appendix defined, than if the surgeon attempts to follow the sinus from the first, not knowing ex actly where he may open the peritoneal cavity. Collins Warren (Boston Med. and Surg. Jour., Oct. 28, "36).