Jansen recommends to be careful in loosening adhesions in cases in which the meal wall is much infiltrated, and to leave out the toilet of the appendiceal stump, as the sutures would cut through easily and then a fistula would form. The stump is only clamped off and tied (perhaps also subserous peeling out (Thevenot)).
We, as well as others, now pull down the omentum in all suspicious looking cases and fix it broadly over the dangerous spot in the intestine.
Fecal fistulm do, however, close up spontaneously after a long time, if no unfortunate accident, such as the formation of a spur, protrusion or prolapse of the mucous membrane, interferes with this. At first we must be patient; the more so the younger the child. We must always remember that an operative closure of a fistula may easily lead to a resection of intestine, an operation which small children rarely survive. To some rare cases we may be able to go in through an incision next to the fistula, loosen the fistulous gut from all sides subcutaneously (the same as we do in umbilical hernim) with blunt instruments, tie it off, invaginate it, and close fascia and skin over it. Should the fistula be of some size, then the defect will usually include most of the circum ference of the intestine. It will usually be impossible to close the loop, which is frequently adherent by a linear suture, so that only resection will have the desired result.
We have given up rinsing out and injecting antiseptics in suppura tive appendicitis. The much lauded treatment with eollargol, per rectum as well as intraperitoneally, has never given us any beneficial results, though we have used it often.
Distant abscesses, subphrenic or left-sided ones, must be opened under the same precautions; and always remember that in the close proximity of the abscesses to the blood-vessels the germs may quite easily spread further (ernpyema, pneumonia).
(d) Invogination and Intestinal Occlusion as a Cause of Peritonitis (Operations in Intestinal Occlusion) For the symptomatology of invagination see Fischl, Intussusception, vol. iii.
Prognosis and treatment of invagination: Whenever a diagnosis of intestinal occlusion has been made it can only be relieved by radical measures. Not only in the congenital occlusions but also in the strangu
lations and invaginations of older children the ileus and the pain in the abdomen will induce the surgeon to operate. Only in that form of occlu sion which is most frequent in infancy, intussusecption, do we still try a reduction with internal measures or non-surgical applications. The reason for this may be found in the good results reported by Hirsch sprung (60 per cent. of cures), which arc quoted again and again, though their correctness is doubted by many (Klemm, Braun). We can expect a cure only when we are able to succeed in the reduction within the first twelve hours. Those cases, in which a successful reduction through a laparotomy is reported as late as after forty hours, were such in which the mesenteric vessels were not entirely shut off, and such cases may at times recover spontaneously and then persist through life (chronic invagination).
A boy of six years was suffering from digestive disturbances for a long time, complained of frequent stomach-ache, and was finally brought to the hospital in an attack of appendicitis and was operated on account of the symptoms. The appendix was found red and swollen; above its base an old invaginaticn was found, which was covered on all sides by peritoneum and did not show any acute symptoms. (This boy had been at the hospital when eight months old on account of an invagination, which had, however, been "reduced" with elysmata.) After removal of the appendix one was able to sect he invaginated but pervious piece of ileum in the CaT11111 (Fig. 115). On account of the weak condition of the patient no resection was performed, but an artificial anus was made instead at the insertion of the appendix, from which one was able to probe the invagina tion. The child recovered, the passage remained free without probing, the stools followed the nat ural channel, and the fecal fistula became but had to be closed later by an operation.
t his case the swelling accompa nying the appendicitis caused an ob struction and the lumen of the intestine, which was not overlarge.