2. Closed abscesses which show a distinct tendency to absorption.
3. Desperate cases with general peritonitis in which the crossed chart (high pulse, low leucocyte-count, low blood-pressure) indicates the losing fight of the body. The majority of these cases perish; a few only may be guided by internal treatment, stimulants and endermoelysis, around the dangerous rocks to where they may be saved by operation.
We must now add some cases which were operated on account of a continuous low fever accompanied by pains in the region of the appendix. In seven cases the appendix was normal and only showed slight redden ing, but in its tip we found nests of oxyurides; in one case we found large numbers of ascarides, and we may therefore be permitted to speak of these cases, which are by no means rare, as helminthic appendicitis.
Operative Findings.—The conditions we find at operation confirm entirely what we considered of importance etiologically. Doubling up, twists, adhesions, strictures of and biologic origin, together with irregularities of digestion, constipation, colitic swelling of the mucosa, all these cause the occlusion of the appendix, the formation of fecal concretions, disintegration of the exudate, and all their consequences (Fig. 143, Plate 13).
The operative prognosis is determined in the first place by the time at which we operate.
Interval operations are almost entirely free from danger, though we must always be prepared for surprises which arc usually due to a complicated location of the organ (adhesions, scars).
Early operations are almost equally safe, when done within the first twenty-four hours. Technically they are easier, because adhesions have not yet made the finding of the appendix difficult. Only the most malignant types of streptococcus-infection detract from the marvelous result of early operation.
The intermediate operation, when abscesses have already formed, gives a bad prognosis only in those cases in which the discrepancy between the virulence and the power of resistance of the patient is too great, or when we are not sufficiently careful at the operation. Its prognosis can
naturally not be quite as good as that of the early operation because it cannot be strictly separated from diffuse peritonitis, and because the mul tiplicity of the abscesses considerably influences the chances of recovery.
The technic of the operation changes according to the type we have to deal with. In early or interval operations, in which we do not expect to meet any difficulties, our special attention must be directed to pre serve the intiscutar activity of the abdominal wall as much as possible, and the permuscular operation through the smallest possible incision is here surely the only method.
After the third day, if no reaction has set in, we may allow these chiblren out of bed (Kammel); on the seventh day we take out the sutures and dismiss the patients.
Should we find a purulent exudate around the appendix, then we wipe this off and drain externally with a glass tube or a piece of rubber tissue (Lennander).
In cases in which we suspect an abscess, we use the para-rectal incision (Lennander, Kammerer), which allows a better view into the abdominal cavity and which guarantees a good muscular closure in case the suppuration does not last too long (provided we have avoided the nerves supplying the posterior fascia).
In other cases the incision must be made according to the location of the abscess, and we may choose among a large number (Sonnenburg, Riedel). We drain clown to the deepest point we can reach (Murphy), and also arrange the patient's position in bed according to this. But we always close the abdominal wall entirely except for the drainage tubes, even in cases of walled-off peritonitis. To avoid fecal fistulae, which formerly were a frequent and unfavorable complication of the healing of these abscesses, we have abandoned the gauze packings. Should we insert strips of gauze, then these should not come in contact with the sutures in the intestine, and rubber-tissue is better.