APPENDICITIS, Acute Form.
The writer regards it as now definitely established that under this title are included two distinct entities: (r) Acute Inflammation of the Appen dix, and (2) Acute Appendicular Obstruction, the latter being the more serious, not only on account of the insidious character of the early symp toms, but also and chiefly on account of the more disastrous, often fatal, sequela: which ensue.
(i) Acute Appendicitis, primarily and essentially an inflammation of the appendix spreading to the peritoneal coating, is characterised by a con tinuous pain beginning in the right iliac fossa, tenderness and rigidity. Vomiting is not a common symptom of this form. The temperature and pulse are elevated. This is a rare form of the disease, so much so, that when the patient in the early stages refers the pain to the iliac region, the observer always thinks of other causes of the illness, such as pyelitis, ovaritis, salpingitis, etc.
(2) Acute Appendicular form includes about 95 per cent. of the acute diseases of the appendix. Here the initial pain is referred to the gastric or umbilical region, or even to the left side of the abdomen, is of a colicky character, and is soon followed by vomiting.
At this stage there is no elevation in the temperature, and the pulse will not be markedly increased in frequency. These symptoms are due to obstruction of the lumen of the appendix, usually by a coprolith or stricture. It is difficult during this stage to identify the disease as due to the appendix, but once the diagnosis has been made no time should be lost in getting appendicectomy performed.
With the diagnosis settled, the patient should be placed in the Fowler position, any food or medicine which will provoke intestinal peristalsis denied, and a small dose of morphia (gr. 1) with atropia (gr. ad ministered hypodermically. If this does not control the pain, hot fomen tations may be applied to the abdomen. Previous to operation a small soap and water enema may be given, but all aperients must be withheld.
By this means an appendix not yet perforated may remain in stout quo until removed by operation, and the results in such cases leave little to be desired in the matter of prognosis, the results being almost uniformly good and the period of incapacity short.
An obstructed appendix left to itself usually proceeds to gangrene. This is recognised by some rise of temperature (99 '-too° F.), increasing frequency of pulse, diminution in pain, but increase in tenderness and rigidity of the right side of the abdomen. Perforation of a gangrenous appendix, a later stage still, is marked by a rising pulse and temporary fall in the temperature and recurrence of pain in the right iliac fossa. Here again the line of treatment already laid down is indicated—viz., rest in Fowler position, denial of food or aperient medicine, and the administration of a small dose of morphia with atropia—these prepara tory to operation, which should be carried out without delay and with the least disturbance of the patient. There should always be kept in mind
the risk of rupturing a thin-walled gangrenous appendix, and the con version of a localised disease of the appendix into a suppurative peri tonitis.
A wholly different problem confronts the surgeon when he is first called to see a patient who has already passed the acute stage of an attack. Some surgeons hold the opinion that even then it is good practice to per form the operation at once; others, however, believe that the operative risk will be lessened by delaying for a time and doing what is called an " interval operation " after all inflammatory symptoms have disappeared.
For removal of a diseased appendix two incisions only are now much used: (I) The gridiron incision running in the direction of the fibres of the external oblique muscle about two fingers' breadths above Poupart's ligament, one half of the incision lying above the line joining the umbilicus with the anterior superior iliac spine, and the other half below it. The external oblique, the internal oblique, and the transversalis muscles are incised in the direction of their fibres; the transversalis fascia and the peritoneum are divided transversely. (2) The incision through the right rectus muscle in the line of its fibres. Both these incisions can be firmly sewn up afterwards, and show little tendency to hernia unless it be found necessary to drain the abdomen. Having opened the peritoneal cavity, the mcum is sought for and hooked up on the index-finger. If necessary the appendix is found by tracing downwards the longitudinal muscle bands of the cxcurn. If pus be suspected it is necessary before disturbing the appendix region to pack off the abdominal cavity with three gauze sponges rung out of normal saline solution—one of these passes up to wards the right kidney, one passes inwards towards the general abdominal cavity, and one passes downwards into the pelvis. Having isolated the appendix, its mesentery is ligatured off in segments; a purse-string suture surrounds the base of the appendix; the base is crushed with a crushing forceps or a strong artery forceps; the crushed portion is ligatured with catgut and the distal portion removed. The ligatured and crushed stump is then disinfected with Tr. Iodi and invaginated within the purse-string suture and the latter tied. Two or three Lembert sutures are inserted to cover the purse-string suture, and the parts returned within the abdo men. The layers of the abdominal wall are sutured with catgut, so as to restore the parts to their normal positions, and finally the skin is closed with interrupted sutures of silkworm gut.