In the absence of complications cases of appendicitis are allowed out of bed about the tenth day, and leave hospital about the fourteenth or fifteenth day after operation.
When suppuration (practically always due to rupture of the appendix) has already occurred, the treatment will depend on other factors: (1) Is the suppuration localised ? (2) Or is there a diffuse suppurative peri tonitis present ? Taking first the case of a localised abscess, the pus may be found in the right flank, in the iliac fossa, in the pelvis, or lying on the posterior abdominal wall. In the first three situations it is generally regarded as good practice to open the abscess without opening the general abdominal cavity. A finger should be introduced and the cavity explored, and a loose appendix or concretion, if present, removed. In the case of an abscess lying on the posterior abdominal wall this must be opened through the general peritoneal cavity, and great care should be exercised by packing to prevent the infection spreading to the healthy peritoneum. Murphy disagrees with the direct opening of abscesses without opening the abdominal cavity, whilst Page, speaking for the surgeons working at St. Thomas's Hospital, believes that no abscess should be opened through the general cavity, but if the abscess be not opened directly a gauze drain should be inserted down to but not into the abscess, so as to form by adhesions a safe track for the pus which later comes away spontaneously, or may be opened by a finger passed along this track. Abscess cavities should be gently swabbed out with gauze, but no lavage, which may drive infection into clean parts of the abdomen, should be allowed. After thorough gentle swabbing out of the cavity a wide-bore drainage tube is introduced.
In suppurative cases there is still a division amongst surgeons regarding the treatment of the appendix itself. Most operators, however, now believe that after evacuation of the pus a thorough investigation of the abscess wall should be made. If the appendix can be detected and iso lated without much disturbance of uninfected tissues it should be removed. Otherwise it should be left and dealt with at a subsequent operation.
When a spreading or general septic peritonitis follows the rupture of an obstructed and gangrenous appendix, one of the most serious of surgical problems confronts the operator. There is, however, as a rule no alterna tive but to give the patient the advantages which prompt interference alone affords. It will generally be found that an incision in the middle line just above the pubis affords the most direct route to the collection of pus, as well as the most efficient for the purpose of abdominal drainage. In late cases this incision can be made under local anesthesia, a wide bore drainage-tube with a gauze wick introduced deep into the pelvis, and no attempt made to deal with appendix. Certain points must be kept in mind in dealing with these cases: (I) They should be disturbed as little as possible; (2) they should be kept in the Fowler position; (3) they should never get chloroform as an amesthctic—if one be necessary, it should be open ether given as sparingly as possible, and preceded by a hypodermic of morphia and atropia.
Upon recovery from the anesthesia the patient is placed in the Fowler position (propped up in bed in the sitting posture), and with a suitable irrigation apparatus saline solution is made to trickle into the rectum not quicker than it can be absorbed. The quantity introduced in this manner skilfully carried out may amount to zo pints in the 24 hours without the least distension of the rectum or colon. The abdominal and pelvic lymphatics being distended and flushed by this means, the danger of septic absorption is reduced to a minimum, thirst disappears, the eliminatory organs are powerfully stimulated and the heart strengthened. Lavage may be resorted to when the vomiting is persistent, but if his condition does not permit of this the patient should be encouraged to wash out the organ by taking large draughts of tepid saline solution. Aperients should be withheld until the signs of spreading peritonitis have abated, and then a full dose of castor oil (8ii.) is the safest and most reliable purgative. Many of these cases develop signs of obstruction, due, according to IIandley, to Ileus Duplex, for which the only remedy is drainage of the bowel through a tube introduced into the first distended loop of gut that comes to hand. In recurrent appendicitis the mortality has been reduced to almost nil by undertaking the removal of the diseased appendix during a quiescent period, and where induration and tenderness or local pain remain after spontaneous recovery of an inflammatory attack the sur geon should warn the patient not to wait for the advent of a second seizure. The purely expectant treatment of these and all other forms of appendicitis, acute or chronic, should be abandoned, owing to the dangers of perforation, gangrene, suppuration, or spreading peritonitis, which may without warning of any kind suddenly supervene during the progress of an apparently mild attack.
As to the cause of appendicitis, it has lately been established by Wilkie and others that at all events the predisposition arises from the alteration in our habits from being largely vegetable eaters to meat eaters. Wilkie has experimented upon an artificially formed appendix in cats, and has shown that complete obstruction in cats fed on rich proteid diet and con taining cwcal content goes on to gangrene and perforation, whilst in animals fed on porridge merely a cystic distension occurs. Prevention would therefore seem to lie along the way of return to vegetarianism associated no doubt with improved habits of life in general, including regularity of meals, thorough mastication, repair of diseased and septic teeth, and perhaps, as Tyson suggests, the return to the primitive attitude during defecation.—S. T. I.