Nicholas Senn.

Practical surgery for the general practitioner online

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the ileocecal region. IIc>t applications always afforded j^roujpt relief, and .she believes
that they were the means of cutting short several of the attacks. When examined after
her admission into the hos])ital, the apj)endix could be felt as a firm cord, and tenderness
was limited to this structure. f)p(ration November 14th. In this case the a||)endix was
directed downward and inward toward the pelvis ; adhesions were old and firm. Mes-
enteriolum was very short and adherent to a|>])en<lix. It was lic(l in several sections.
Abfjut one-fourlh of the lumen on the [)roximal side was oblilcralcd, and the corrcs|)ond-
ing |)ortion of the a|)pendix was transformed into a firm fibrous coril (I'ig. 4'j5)- i5<"yond
this (jblilerated part the lumen was much dilated, and subdivided into two une(|ual i)or-
tions by a thin partition composed of cicatricial tissue. Wall of a|>pendix was much
thickened afirl dense. B(jth compartments containe<l inspissated pus, which resembled
lif|uefied caseous material. Lymphatic glands in the vicinity of the ajjpendix were much
enlarged and exceedingly vascular. J'atient recovered without an unt<jward .symptom.



A small stitch abscess at the end of a week gave rise to a slight elevation of temperature,
and slightly retarded the healing of the wound.

Case 4. — J. H. Croskey, aged thirty-three, American ; farmer by occupation ; resi-
dence, Farmer City, 111. Entered St. Joseph's Hospital December 5, 1893. Family
history good. Patient was never sick until Nqvember, 1891, when, after a hard day's
work, he experienced a dull pain in right side and lower part of abdomen. He was able
to sit up, but could do no work for three days, when all symptoms passed away. There
was no nausea or vomiting ; a little tympanites and constipation were present. He
attributed the difficulty to a strain produced by lifting. The second attack in April, the
following year, commenced with a sudden, sharp, intense pain, confined to the right side,
in the region of the appendix. The acute symptoms continued for one month, during
which time he was confined most of the time to bed, but at any time, if assisted to his
feet, he could walk with the aid of a cane. During the second month he improved suf-
ficiently to resume his work. A sense of soreness and tenderness in the ileocecal region re-
mained. Vomiting occurred on the evening of the second day. Tympanites was absent.
Diagnosis of appendicitis was made on the fourth day by the attending physician. Third
attack occurred in February, 1893, and resembled the second in every respect. There
remained not so much tenderness on pressure as a soreness or pain from a slight jar, as
would happen when riding in a buggy when the wheel struck a stone. Could not stand
perfectly erect, but would incline the body slightly forward and to the right, with feet about
twelve inches apart. Examination before operation revealed tenderness in the region of
the appendix on deep pressure. Operation December 8, 1893. The appendix was readily
found, as it was directed forward and to the right, occupying a groove in the caput coli.

Fig. 465. — Appendicitis obliterans : I, Proximal end completely obliterated ; 2,
narrow stricture dividing completely the remaining lumen into two unequal portions ;
great thickening of wall near distal end.

Separation from the cecum was very difficult, as the peritoneal coat of the latter appeared
to be absent and the muscular coat very much attenuated. The dissection was made
slowly and carefully, and mainly with the aid of blunt instruments. The mesenteriolum
was incorporated so firmly in the adhesions that ligation was rendered superfluous. A
number of bleeding points were ligated. The appendix, when removed, measured three
inches in length, and on slitting it open it was found that about one-third of its lumen on
the distal side was completely obliterated. The distal end tapered into a sharp point.
The wall of the remaining portion was only slightly thickened. Mucous membrane was
intensely congested. At a point about half an inch distant from obliterated part both
the wall of the appendix and its lumen showed changes that indicated the first stages of
the formation of a circular stricture. Mucous membrane was much thickened.

In this case the second attack of appendicitis produced an intense
localized plastic peritonitis that gave rise to the extensive and firm
adhesions of the appendix to the cecum, rendering the operation one
of great difficulty.

Case 5. — James McChane ; occupation, farmer ; aged thirty-five years ; married ;
mother died of phthisis. Personal history: Never a very robust man. Had "ague"
eight years ago, lasting three months. Regular in habits ; no venereal history.

In August, 1893, the patient, while threshing wheat, was attacked with a severe
paroxysm of pain in the right lumbar region. He had to stop work, but did not go to
bed. He has not been able to do a day's work since, although he has not been con-
fined to his bed. The pain was always present, — a dull aching pain,— and the least
exertion aggravated the difficulty and tenderness. The pains were always referred to the
same pomt— a few inches to the right and below the umbilicus.


The bowels were constipated, and the patient resorted to the use of enemata to relieve
them. The appetite was very poor, and he lost flesh steadily. When admitted, the
patient's temperature was normal in the morning, with a slight evening rise.

On physical examination, a point of tenderness was found corresponding to Mc-
Bumey's point, with some induration afid fixation of the head of cecum.

From the clinical history and existing symptoms it was not difficult to make an
almost positive diagnosis of appendicitis obliterans before the operation. The operation
was perfomied in the clinic of Rush Medical College. The distal end was patulous, and
the proximal end completely obliterated.

The cases just reported present man}' clinical features in com-
mon. The age of the patients varied from twenty-five to thirty-
eight. Four were males, and one was a female. In all of them the
acute exacerbations were characterized by s\mptoms of peritonitis
of varying intensitx'. Swelling docs not appear to have been a con-
stant feature, either during or after the acute attack. In most
instances the pain was at first diffuse or referred to the epigastric
region ; later, localized in the ileocecal region. In most of the
cases tenderness in the region of the appendix remained a long time
after tiie subsidence of the acute .S)'mptoms, or persisted as a perma-
nent condition. The point of tenderness varied according to the
location of the appendix. The febrile disturbance during the acute
attack appears to haxe been moderate and of short duration.
Nausea and vomiting were not con.stant .symptoms. Tympanites
depended on the extent of the peritoneal involvement. The most
constant and characteristic feature was recurrence of the acute
exacerbations, which set in from once a year to every few weeks.
As a rule, the attacks become gradually more frequent. In two out
of the five cases, some of the important s\'mptoms remained in a
masked form during the intermissions. This was noted particular!}'
in the cases in which the appendix was obliterated on the proximal
side. Absence of complete intermis.sion between attacks points to
the existence of stenosis or obliterations on the proximal side.

From what has been saitl it will be seen that the most conspicu-
ous .symptoms of this form of appendicitis are : (i) Short duration
and moderate intensity of the acute exacerbations ; (2) slight or no
swelling in the region of the appendix ; (3) recurrence of acute
attacks, varying in frequency from a year to .several weeks ; (4)
persistence, during the intermission, of some .soreness and tenderness
in the part affected.

Ribbert wished to ascertain the frequency with which the appen-
dix vermiformis undergoes obliteration, and for this purj) noted
the condition of this organ in 400 postmortem examinations. He
found partial or complete obliteration in 25 per cent, of these cases.
Jfe believes that this change is due to involutionary changes in the
majority of cases. One reason for entertaining this idea is that this
condition of the appendix is met more frequently in persons advanced
in years. The influence of age is shown in the following table :

1 decennium 4 per cent. 5 flcccnnium 36 per cent.

2 " 17 " (> " 5.^ "

4 " 27 " 7 " 5S "



In favor of the inflammatory origin of appendicitis obliterans it
can be said that appendicitis is a comparatively rare affection in chil-
dren, and that the longer the person lives, the greater the liability
to suffer from an attack. There can be but little doubt that obliter-
ation of the appendix occasionally occurs as a congenital condition.
Atresia of the lumen of this organ is probably more liable to occur
during intra-uterine life than is the same condition in other parts of
the gastro-intestinal canal.

Pathology and Morbid Anatomy. — Ran vers found the appendix
completely obliterated in thirteen postmortem examinations. All
the specimens showed evidences of circumscribed plastic peritonitis.
He believed that in some of these cases perforation had taken place,
and that the disease ultimately cured itself In one specimen he
found a small fecal concretion surrounded by a capsule of cicatricial
tissue. Tlie most striking morbid changes in obliterating appendi-
citis are found in the different tissues of the organ, and these are
directly concerned in the gradual and progressive obliteration of its
lumen. A stricture of the appendix, like that of any other hollow
organ, may be brought about by : (i) Destruction of the mucous
membrane by ulceration ; (2) infiltration, thickening, and contraction
of the muscular coat ; (3) prolonged cicatricial contraction of exu-
dates upon its serous covering ; (4) in consequence of a combina-
tion of two or more of these causes.

The obliteration is always preceded by destruction of the epithe-
lial lining by the inflammatory processes, aided later by cicatricial
contraction following the healing of the ulcerating surface by gran-
ulation. Epithelial remains in the scar tissue are finally destroyed
by the progressive cicatricial contraction and avascularization.

Perforative Appendicitis. — The tissues around the appendix,
particularly the peritoneum, may or may not be involved in catarrhal,
ulcerative, or obliterating appendicitis. In perforative appendicitis
the complicating para-appendicular affections constitute the most con-
spicuous part of the clinical picture. An acute necrosis of the wall
of the appendix over a limited space may result in perforation within
forty-eight hours, followed by circumscribed or diffuse phlegmon or
peritonitis, according to the location and size of the perforation and
the amount and virulence of the infective cause. Postmortem exami-
nations have shown conclusively that, with few exceptions, perityph-
litis and paratyphlitis are preceded by a primary appendicitis, so that
in all acute inflammatory processes in the ileocecal region an appen-
dicitis must be suspected as the primary cause. Every perforative
appendicitis is followed by peritonitis of greater or less extent. A
retrocecal phlegmonous inflammation will occur if the perforation
takes place in this direction, which can occur only by the accident
being preceded by a plastic peritonitis shutting out the peritoneal
cavity from the focus of infection. In such an event the subsequent
course of the disease is attended by signs and symptoms of acute
abscess formation behind the cecum. Such an abscess may find its


way as far as the under surface of the liver, simulating a paranephric
abscess, or it may reach the surface near the spine of the ilium or
above Poupart's ligament. In other cases the perforation leads to
a plastic peritonitis that walls off the peritoneal cavity and the
abscess, intraperitoneal from the beginning, may rupture into the
cecum, a loop of the small intestine, the rectum, bladder, or va-ina
I he most serious consequences occur in cases of perforation with
the escape of the inflammatory product into the free peritoneal cavity
in which event a diffuse septic peritonitis and death are the usual
consequences unless the latter can be prevented by prompt opera-
tive interference. In case the perforation is small and a plastic peri-
tonitis limits the escape of septic material, suppuration does not
lollow as an inevitable result. In such instances a hard inflamma-
tory- swelling makes its appearance, which in the course of time dis-
appears by absorption, leaving the appendix embedded permanently
in adhesions.

In relapsing appendicitis the inflammatory swelling appears
toward the end of the acute exacerbation, uhen it diminishes in size
or disappears entirely, to reappear during the next attack. Perfor-
ation may follow recurring attacks of appendicitis as the result of a
chronic ulcerative process, usually in combination with a mechanical
obstruction, but in the great majority of cases it presents itself
clinically as an acute process, perforation taking place in from a few
hours to several days from the beginning of the first symptoms.
The pathologic anatomy in such cases presents, as the most con-
spicuous feature, a circumscribed necrosis of the wall of the appen-
dix. If a fecal concretion is present, the perforation usually corre-
sponds to its location, which would indicate that the pressure caused
by the fecal concretion in the inflamed swollen appendix had some-
thing to do with causing the necrosis. In the absence of such a
local cause we must assume that the inflammation eventuates in
necrosis by obstructing the vessels in the necrosed territory.

Gangrenous Appendicitis.— In this form of appendicitis a part
of, or the whole appendix is destroyed. (Gangrenous appendicitis is
alwavs an acute process. The inflammation and the conditions in-
duced by it may be so .severe that gangrene takes j^lace in the course
of twenty-four hours. I have seen a number of cases of appendicitis
in which laparotomy was performed in less than thirty-six hours
after the appearance of the first .symptoms, and found in such in-
-stanccs tlie entire organ gangrenous. The caieful examination
of the specimens removed showed no evidences of perforation. In
two ca.scs of gangrenous appendicitis that recovered after the abscess
ruptured into the bowel, pain and tenderness remained in the right
iliac, where a limited induration could easily be detected.
Operation several years after the acute attack revealed about half an
inch of the di.stal end of the appendix buried in a of ad-
hesions, and entirely detached from the cecum. In both specimens
the lumen of the isolated ];art of the organ contained a few drops of



a viscid fluid of a brownish color. The gangrenous portion in both
of these instances was ehminated with the contents of the abscess,
and the survival of the tip of the organ must necessarily be attributed
to a separate blood supply, either through blood-vessels in ante-
cedent adhesions or from other source aside from the principal artery
of the appendix. Total gangrene of the appendix is always associ-
ated with thrombosis of the principal blood-vessel, and the complete
arrest of the circulation is the direct cause of the gangrene. Mal-
position of the appendix, abnormality of its principal blood-vessels,
and acquired conditions that interfere mechanically with the necessary
blood supply are undoubtedly the most frequent and potent predis-
posing causes of the gangrenous inflammation. The direct imme-
diate cause, however, is to be found in the infective process which
determines the thrombosis. The veins. undoubtedly are always first
occluded by a progressive thrombophlebitis, which extends from the
inflamed wall to the mesenteriolum, resulting finally in occlusion of

the principal vein that returns the blood
from the appendix and the meso-appen-
dix. The complete arrest of the venous
circulation is soon followed by throm-
bosis on the arterial side, complete arrest
of the circulation, and the inevitable re-
sult — gangrene.

Fis". 466. — Distal portion of tt 1 j. • 1 i. i. i.

append^ isolated from the cecum . Unless prompt surgical treatment
and embedded in scar tissue after is resorted to, gangrenous appendicitis
an attack of gangrenous appendi- \q^^. jn a great majority of cases, to

citis. Ihe lumen contained a . ... i 1 1 t^i

gelatinous substance, and a cul- septic peritonitis and death. 1 here are,
tare made from it yielded a however, exceptions to sucli a course.
growth of staphylococcus pyo- y^^^^ favorable circumstances a plastic

genes albus. ...... - ^

peritonitis limits the infection, and ab-
scess forms in which the detached gangrenous appendix is "later
found as part of its contents. But even under the most favorable
circumstances the disease pursues a very rapid course and demands
operative treatment as soon as a diagnosis can be made.

Symptoms and Diagnosis. — The symptoms of appendicitis must
necessarily vary according to the pathologic forms of the disease
and the absence or presence of peritoneal complications. In per-
forative and gangrenous appendicitis the primary affection is soon
overshadowed completely by the resulting peritonitis. The local
symptoms are most characteristic in the catarrhal and obliterating
varieties. In such cases the pain is usually referred at first to the
region of the umbilicus, for the reason, as has been suggested, that
during the early stages of the embryologic development of the in-
testinal canal the appendix is found in that locality. In this respect
the appendix furnishes an analogy to the testicle, in which, when the
seat of a painful affection, the pain is referred, in part, at least, to a
point occupied by the organ during embryonic life. Others believe
that this distant pain is caused by a reflex implication of the great


sympathetic ganglia situated in that region. The characteristic
pain of appendicitis corresponds with the location of the organ, the
attached portion of which is found almost invariably, as was pointed
out by McBurne}', on a line drawn from the anterior superior
spinous process of the ilium to the umbilicus, and about half-way
between these two points. This is McBurney's point, so constantly
referred to in the discussions on inflammatory affections of the
appendix and their operative treatment. This point corresponds
with the cecal end of the appendix, while the organ itself may be
found displaced in almost any direction and any part of the abdomi-
nal cavity. The appendix has been found in the pelvis, in the region
of the sigmoid flexure or of the umbilicus, and even under the surface
of the liver, but its origin from the cecum is almost constant and
corresponds with McBurney's point.

Tenderness is a more important diagnostic evidence than pain.
In the absence of peritonitis the tenderness is limited to the inflamed
organ and serves as a guide to its location. In catarrhal and
obstructive appendicitis the pain is often colicky, and has been
referred to exaggerated peristalsis (Morris), constituting the so-called
appendicular colic. The inflammatory swelling incident to appendi-
citis varies in size and character according to the amount and nature
of the inflammatory product.

The normal appendix can seldom be outlined by palpation,
which is contrary to what has been asserted by Edebohls and
others. It is usually fowid difficult to locate the slightly enlarged
appendix by palpation, and the absence of a palpable szvelling does not
exclude the presence of a catarrhal appendicitis. If the appendicitis
has given rise to a circumscribed peritonitis, a hard and tender
swelling, variable in size, indicates the exact location of the diseased
organ. If the appendix is located behind the cecum, as is so often
the case, a swelling of considerable size may elude palpation. Owing
to the tenderness and rigidity of the abdominal wall, it is extremely
difficult to detect fluctuation if suppuration has taken place unless
the abscess is large or has reached a stage where it has resulted in
a marked bulging of the abdominal wall. So far as palpation is
concerned, a large retrocecal intraperitoneal abscess often very closely
simulates an extraperitoneal abscess. Muscular rigidity is a promi-
nent clinical feature of appendicitis, and, as a rule, it is proportionate
to the severity and extent of the complicating peritonitis. Retraction
of the thigh is an indicatio?t of the extension of the ijiflammation in
the direction of the sheath of the iliopsoas muscle, and is met most con-
stantly in retrocecal suppuration.

The treacherous nature of appendicitis becomes more suspicious
in the study, at the bedside, of general than of local symptoms. The
gravest cases are often initiated by a comple.xus of symptoms that
furnish no indication whatever of the lurking danger hidden behind
it, and mild cases often present themselves attended by symptoms
indicative of a far graver conditifjii than really exists. The



and temperature are especially misleading, more particularly so in
children. I have operated repeatedly in cases in which the consti-
tutional symptoms were of a severe type, and found, to my utter
astonishment, a plain case of appendicitis without perforation or
peritonitis to any considerable extent. I have been lured into a
sense of security by a temperature not far from normal and a good
pulse, and found, a (ew days later, when forced to operate by a sud-
den aggravation of the symptoms, a gangrenous or perforated ap-
pendix, extensive pus-formation, or a diffuse septic peritonitis. It is
the difficulty of interpreting correctly the early symptoms of appen-
dicitis that makes it often so trying a task to decide whether to oper-
ate or to pursue a conservative course. While the initial symptoms
are well calculated to leave doubts in the mind of the surgeon as to the
propriety of resorting to operative interference, there can be no ques-
tion as to the advisability of doing so when the symptoms increase
progressively in intensity. If the temperature continues to rise and the
pulse increases in frequency after the first tzventyfour hours, it is safe to
assume that the appendicitis has resulted in complications that tvar-
rant operative treatment. The same can be said of a gradually in-
creasing tympanites. Vomiting is a frequent, but by no means a
constant, symptom. The disease is often preceded and accompanied
by constipation, but the reverse may be the case.

In the differential diagnosis between appendicitis and the affec-
tions resembling it the greatest care is required, as healthy appen-
dices have been repeatedly removed for symptoms caused by other
diseases, and many cases of appendicitis have been overlooked and
treated for other affections when, perhaps, operative treatment was
urgently indicated. The most important symptoms upon which to
base the diagnosis of appendicitis are the following : Pain and tender-
ness in the region of the appendix, fever, muscular rigidity, tym-
panites, vomiting, and very often either constipation or diarrhea.
Another circumstance important to remember is that the attack is
usually ushered in suddenly without any premonitory symptoms.
In the grave forms of the disease progressive aggravation of symp-
toms is to expected, although sometimes the acute symptoms
diminish in severity after a few days, and a lull precedes the subse-
quent more stormy and progressive symptoms.

Typhlitis in many respects very closely resembles appendicitis,
but the rarity of this disease as compared with appendicitis must be
remembered in making the differential diagnosis between these two
acute inflammatory affections in the ileocecal region. Typhlitis is
usually attended by coprostasis, and the existence of a doughy
swelling in the cecal region during the beginning of the attack
speaks strongly in favor of typhlitis. If any doubt exists, the ad-
ministration of a laxative and a high enema will often promptly
confirm or correct the diagnosis.

Tuberculosis of the cecum is a chronic affection and lacks most
of the clinical features that characterize appendicitis.



It is more difficult to differentiate between some forms of
mechanical intestinal obstruction and appendicitis. As a rule, in

Online LibraryNicholas SennPractical surgery for the general practitioner → online text (page 76 of 128)