type of malignant tumor is the round-cell carcinoma, epithelioma rarely
appearing except in the lower part of the rectum, where flat epithelium
is met. Adenocarcinoma, then, is common, and sarcoma relatively rare,
the latter arising, of course, from mesoblastic elements. A diagnosis
is made by first noting symptoms of intestinal obstruction plus
certain added features of cachexia, lymph involvement and possibly of
metastasis, for which a benign stricture would not account. Sometimes
a tumor is easily felt within the abdominal wall; at other times
one simply makes the general diagnosis of intestinal obstruction,
presumably cancerous, because of age and cachexia, and leaves the rest
to be determined by operation. Cancer of the bowel will naturally
spread in the direction of the lymphatics at the root of the mesentery,
and these will nearly always be found involved. It is fortunate if a
case may come to operation before this invasion has occurred.
=Treatment.=--Cancer of the bowel permits of but two methods of
treatment, one _excision_ of the entire infected area, both of
bowel and of mesentery, in cases not too excessive, the other an
_anastomosis_, by which temporary relief at least may be afforded. In
all cases I am strongly inclined to advise the use of the _x_-rays,
for a long time after operation; in favorable cases because it exerts
a prophylactic influence, in the unfavorable cases because it nearly
always relieves pain and retards growth, seeming sometimes even to
disperse it. Such treatment should always be tempered by the best of
judgment, lest _x_-ray dermatitis complicate or prevent it.
ACUTE INTESTINAL OBSTRUCTION; ILEUS.
The somewhat badly derived and indefinite term “_ileus_,” in common use
abroad, is coming into more fashionable use in the English-speaking
profession, which is rather unfortunate, for it has not always meant
exactly the same thing in the writings of different authors. It will
be used, however, in this chapter as practically synonymous with acute
obstruction or strangulation.
Acute obstruction may be classified in two ways, as to types and as to
causes. For the first purpose the best classification is perhaps the
simplest, and, as recently rehearsed by Murphy, is as follows:
1. Adynamic, including those conditions which are due to absence of
power of propulsion.
2. Dynamic, where obstruction is due to excessive power or excessive
contraction of the muscular wall.
3. Mechanical, including all of those conditions of strangulation
or obturation which, in a mechanical way, impede the advance of
intestinal contents.
Conditions which permit the adynamic type may include those of _spinal
origin_, those interfering with mesenteric _nerve supply_ or that of
the walls of the intestines (for instance, in cases of fracture of
the spine), or, again, where extensive operations have been performed
on the mesentery, or where there have been extensive wounds. Thus in
removal of mesenteric tumors, unless care is exercised in separating
the mesentery from the tumor and in ligating bloodvessels without
including nerves, a paralytic ileus may promptly result. Gunshot wounds
of the chest or of the spine may also include _injuries to nerves_, by
which paralysis of the bowel ensues. So, too, adynamic ileus sometimes
results through the _paralyzing reflexes_ which follow strangulation of
the omentum--as, for instance, in a hernial sac--or it may be due to
biliary calculus acting in the same way.
The dynamic forms, as well as the mechanical, are much more likely
to be characterized by pain and violent symptoms than are the
paralytic. _Gastric tetany_ is a condition to be differentiated
from reflex ileus. _Enormous distention of the stomach immediately
after operation_ leads perhaps to a belief that a patient has acute
obstruction of the intestine, when the fact is that such a case
may be relieved by vomiting or passage of a stomach tube. _Local
peritonitis_ of septic type, as well as peritoneal traumatism, tends
to weaken if not to paralyze peristalsis. In general peritonitis the
entire intestinal tract is involved, partly from reflex paralysis,
partly from inflammation of the intestinal wall. The _embolic type of
paralytic ileus_ may be due either to interference with nerve supply or
with blood supply. In thrombophlebitis symptoms develop more slowly,
especially when this follows abscess of the liver or spleen. Here there
is not so much meteorism, and the bowel may be even nearly empty, while
we have the other symptoms of pain, nausea, and vomiting. Borborygmus
is one of the most pronounced manifestations of mechanical ileus and
the stethoscope will then give much assistance. In fact auscultation
of the abdomen, with a recognition either of active motion within or
of absence of peristalsis, should not be neglected; when one can hear
intestinal waves the condition is much more likely to be one of purely
mechanical obstruction.
Classified by causes, we may make out the following well-marked groups:
1. Strangulated hernia of all varieties, including diverticula.
2. Intussusception.
3. Volvulus.
4. Ileus from fecal impaction.
5. Stricture.
6. Intrinsic neoplasms.
7. Extrinsic neoplasms.
8. Gallstones and foreign bodies, enteroliths, etc.
9. Peritonitis, with paralytic ileus or kinking of bowel by
adhesions, or both. This condition is seen in severe cases of
appendicitis.
10. Bands, congenital and acquired, recent and old.
11. Slits and apertures in the mesentery or omentum.
12. Effects of contraction and intestinal looping.
13. Congenital causes, including diverticula, unobliterated
omphalomesenteric and hypogastric remains, etc.
1. =Strangulated Hernias.=--By far the most common of all the causes of
acute obstruction are strangulated hernias. These are, however, treated
by themselves in a distinct chapter.
2. =Intussusception or Invagination.=--These terms imply a protrusion
or prolapse of one part of the intestine into the lumen of an
immediately adjoining portion. This is found to be the cause of perhaps
one-third of the total number of cases. Enteric invaginations occur
along any portion of the small intestine, being more common in the
lower portion and rare in the uppermost. They seldom attain great
length and are often very short. The ileocecal is the most common
variety, since obviously it is the easiest of occurrence, the ileum
protruding into the cecum or the ileum and cecum together passing into
the ascending colon. Colic invagination may occur anywhere along the
large bowel, being again more common near its distal termination. The
colon may descend into the colon or the sigmoid into the rectum, even
to such an extent as to present at the anus or possibly protrude.
Statistics show that the ileocecal occurs in 44 per cent., the enteric
in 30 per cent., the colic in 18 per cent., and the ileocolic in 8 per
cent. of cases.
While the surgeon is concerned only with the obstructive form of
intussusception it is of interest to know that the condition occurs
occasionally shortly before death and is then spoken of as the
_intussusception of the dying_, being usually due in these cases to
irregularity and uncertainty of peristalsis during the concluding hours
of life; paralysis occurring at one portion of the intestinal tube and
abnormal activity just above it. These conditions are discovered at
autopsy, and can be recognized as such by the absence of exudate or of
any attempt either at repair or inflammation. They occur most commonly
in the young and may also be multiple. In direction intussusception is
practically always descending, although there may be a secondary and
associated ascending movement, the latter being unimportant.
_Double_ intussusceptions are somewhat common, and triple or multiple
have been described.
Cross-section of an invaginated bowel will show that on each side one
must pass through three distinct layers of bowel wall. That portion
which is intruded is spoken of as the _intussusceptum_, while that
portion which receives the latter is known as the _intussuscipiens_
(Fig. 560). Obviously when invagination occurs the mesentery should
be drawn in with the intussusceptum, while traction upon it should
increase with advance of the included bowel. This is particularly often
seen in ileocolic varieties where the ileum, with its mesentery, may
travel the whole length of the colon and even present at the anus.
Moreover, this may occur within a relatively astonishing short time,
and the fact that the intussusceptum may be felt in the rectum within
a few hours after the occurrence of the first symptoms is a fact not
easily to be explained.
[Illustration: FIG. 560
Diagrammatic section of an intussusception: _A_, reflected tube; _B_,
receiving tube or sheath; _C_, entering tube.]
=Causes.=--The causes of intussusception are obscure, postmortem
findings or even the revelations of a laparotomy demonstrating
conditions, but not often affording explanations. The presence of
tumors, especially lipomas, which may even be pedunculated along the
small intestine, has been demonstrated in a number of instances, and
they have been supposed to be active factors in the first disturbance.
Everything points to the association of disordered intestinal movements
with the mechanical condition of obstruction, and the former are more
frequently seen in the intestinal complaints of the young, along with
the presence of masses of undigested food or impacted feces within the
bowel, or the occurrence of intestinal polypi. The most complicated
case of ileocecal invagination which ever came under my notice was
associated with the presence of a polyp in the ileum. All of these
conditions, save the presence of tumors, pertain more frequently to
the young than to the aged. The influence of the ileocecal valve is
also undeniable, and that at this region parts are more predisposed to
invagination than elsewhere is quite obvious. In at least half of the
cases that have been recorded no satisfactory cause could be shown.
Any condition which causes severe intestinal colic may give rise to
intussusception; the next most common causes are paralysis or weakening
of some part of the bowel, such as may follow injury or disease, or the
presence of tumors, while even the role which they play is not entirely
explained (Fig. 561).
That invagination will produce mechanical obstruction is obvious,
while the fact that such obstruction is not always nor necessarily
complete incites surprise. The orifice of the intussusceptum is
distorted, while the included portion may be greatly bent or curved
upon itself, in addition to which the obstruction to the circulation
leads to congestion, exudation, and swelling, and predisposes to
active inflammation, all of which tend to still further narrow the
passage-way. If, in addition to this, some tumor or hardened fecal
mass be included in the grasp of the bowel involved it may be seen
how complete shutting off of the intestinal tube may occur within
a few hours. Invagination having occurred tends quickly to become
irreducible; most commonly by the formation of adhesions, as lymph
quickly exudes and bowel surfaces are by it thus glued together. Such
adhesions may persist throughout the whole involved length of bowel
or may occur at various scattered spots. As pressure becomes greater
circulation of the invaginated portion is impeded and finally shut
off, gangrene of the intussusceptum thus resulting. Cases occasionally
terminate favorably through this actual condition, the included portion
being finally cast off as a slough and passing onward and outward. It
is on record, for instance, that six feet of invaginated bowel have
thus been obtruded from the rectum after having sloughed, the patient
eventually recovering. While this possibility, then, is present it is
never safe to wait for it, and it is to be regarded simply as a happy
accident when it occurs. Unless, then, a case of intussusception be
very early and promptly operated, the included portion of the bowel may
be regarded as dangerous and unsafe, unless upon disengagement it prove
to have been but very slightly affected. Even then there is danger of
immediate recurrence of the previous condition because of distention
of the bowel above, paralysis of the part disengaged, and stretching
of the part below. In proportion as obstruction becomes more complete
distention of the bowel above the lesion, from accumulation and gas
formation, will cause more and more distress, until finally complete
paralysis of the muscular coat and possibly eventual rupture may
terminate the case.
[Illustration: FIG. 561
Invagination of ileum, cecum, and ascending colon into transverse
colon. One probe is passed into the appendix, the other into the
invaginated portion of the ileum. (Rafinesque.)]
In addition to the conditions above described, all of which are acute,
there is known also a _chronic form of intussusception_, whose whole
course is much slower and less severe, where symptoms of obstruction
never become more than partial, but may involve any portion of the
bowel, and with about the same relative frequency as the acute forms.
Such a condition in the rectum, for instance, has been mistaken for
cancer.
=Symptoms.=--The special symptoms by which intussusception may be
recognized, or at least by which suspicion is aroused, are, in addition
to those common to all forms of acute obstruction, the _abrupt onset_,
which may even occur during sleep, the _late_ rather than the early
occurrence of _vomiting_, complaint of _tenesmus_, the _wave-like
or colicky character of the pain_, and the fact that along with the
violent peristalsis of which this colicky pain is an indication
_diarrhea_ is a common accompaniment, the actual local coprostasis
being masked by this fact. As the lumen of the bowel becomes occluded
and fecal matter fails to pass, the _evacuations become more bloody
and contain little but mucus_. Finally, almost pure blood may be
passed. _In no other form of obstruction is the passage of blood so
distinctive as in this._ Urine elimination is but slightly influenced,
and strangury is an exceedingly rare feature. Meteorism is also less
pronounced. The discovery of a _tumor_ formed by the invagination
will lend further aid in diagnosis. It may be felt either through
the abdominal wall or by the rectum, and may be noted in about half
of the cases. It is most frequently found in the ileocecal and colic
varieties, and felt in the rectum with the lower colic forms. In
children it is more distinct than in adults. The tumor may even take
the outline of the involved bowel, is usually movable, but may be
fixed. When such a tumor is felt within the rectum it may have to be
distinguished from some intrinsic neoplasm of the lower bowel; but the
history of the case should prove satisfying if the physical examination
leaves one in doubt.
=Treatment.=--_Spontaneous cure of an intussusception_ by a sloughing
process has been mentioned above. Cure may also occur by spontaneous
reduction. It would seem possible also only in recent cases and in the
enteric forms. Cure may also occur by formation of a fecal fistula,
although this is most rare.
3. =Volvulus.=--The term “volvulus” implies some form of twisting or
of revolution of a part of the bowel upon itself or its mesenteric
axis, the result being knotting or intertwining of intestinal coils to
an extent causing their partial and finally complete obstruction. A
common site for volvulus is the sigmoid flexure. Still no part of the
intestine which hangs loosely is exempt.
The most common causes of volvulus are chronic constipation and fecal
impaction, with distention and ptosis. Intestine thus displaced and
overloaded becomes more or less paralyzed, its circulation more or
less impeded, and any twist which has once occurred is not likely to
right itself. The twisted loop having been engorged becomes distended
with gases, and thus tends to increase the difficulty. In these cases
the bowel loop is closed at both ends. Unless relief be afforded by
operation it is a question merely of how soon the loop will become
gangrenous from aggravation of every one of the features above
recounted. Bowel thus involved permits easy passage of bacteria, and
thus to the other features are rapidly added a septic peritonitis. The
resulting abdominal distention may appear early and will become more
prominent.
4. =Ileus from Fecal Impaction.=--A condition of extreme coprostasis,
or fecal impaction, to a degree producing actual obstruction, may
occur without necessary volvulus or twisting of any portion of the
bowel. As fecal impaction increases the overloaded bowel becomes more
and more paralyzed until there may occur final and complete arrest of
peristalsis, with gradual development of symptoms of obstruction. The
longer the condition persists the less the prospect of restoration of
peristaltic movement. Moreover the condition may be complicated by the
development of ulcers above the obstructed segment, known as _stercoral
ulcers_, due partly to gangrene from pressure and partly to the
chemical effects of long-retained decomposing material. They may appear
as sloughs of the mucous membrane and finally lead to perforation.
This form of ileus is more common in the large than in the small
intestine, and especially so in the cecum. Here there is little chance
of retrograde movement, while fecal matter coming down from above will
continue to pack the colon, and thus the cecum may have to bear the
brunt of great pressure. The amount of fecal matter which may be thus
collected is sometimes astonishing, for the bowel may dilate to the
diameter of six or even ten inches, and contain many pounds of impacted
feces. Such masses of collected feces can usually be palpated through
the abdominal wall, and will at least indicate the location of the
principal disturbance, if not its actual character.
5. =Strictures.=--The most common causes of cicatricial stenosis in
large or small intestine are the results of cicatricial contraction
following recovery from local ulceration or repair of injury, as,
for instance, after reduction of a strangulated hernia. The exact
character of the ulcer does not matter. Any lesion which may granulate
and heal will also contract, and the extent of the stricture will be
proportionate to the area first involved. Should this extend well
around the mucous membrane there may be a distinct annular stricture.
Stricture may also result from infiltration and thickening in
connection with a more active diseased process, and such a condition
may be multiple. This is particularly true in cancerous involvement of
the bowel.
Previous history of the case will shed much light on the probable
existence of intestinal stricture. Thus a history of typhoid, of
dysentery, of tuberculosis, or of syphilis will be most suggestive,
for in any of these diseases there may be numerous intestinal ulcers.
A history of hernia, reduced or operated, or of injury, is also of
importance, as also is one of operation upon other viscera, especially
within the pelvis, the lower bowel being often involved in a disease
process within this cavity which may have left its marks.
[Illustration: PLATE L
Enterolith with Gallstone for a Nucleus; Removed by Enterotomy.
(Richardson.)
This patient was a man of sixty-nine, with symptoms of complete
intestinal obstruction. There was no previous history whatever of
gallstone. The impaction was high up in the small intestine. The
gallstone was removed by a small linear cut which was satisfactorily
sutured. The patient died in the course of twenty-four hours.]
Stricture may be recognized by the gradual course of the case and by
a history of increasing difficulty or of increasing constipation. A
stricture as such is not formed within an hour, and in this sense is
the result of a previous more or less active disease. This is true,
also, of cancerous stricture.
6. =Intrinsic Neoplasms.=--The possibility of both innocent and
malignant tumors occurring within the intestinal structures has already
been considered. It is obvious that any such growth will cause gradual
obstruction by the usual process, or may precipitate by its presence
the occurrence of intussusception, of volvulus, or of some kinking by
which obstruction is suddenly produced.
7. =Extrinsic Neoplasms.=--What has been said above applies equally
well to growths not primarily involving the intestine, but encroaching
upon it. Thus obstruction may gradually result from retroperitoneal
growths, or from the impaction of a growing uterine myoma pressing upon
the rectum and finally occluding it. Also cancers growing in various
locations encroach upon and finally involve the bowel in conditions
which nevertheless were originally quite external to it.
8. =Gallstones.=--In the section devoted to the biliary passages
the accidents which may occur during gallstone disease have been
summarized, and it has there been related how large ones may ulcerate
through and drop into the small or even into the large intestine.
Enteroliths may be thus produced, which were originally small
gallstones that have lodged and grown by accretion until they have
reached considerable size, or by gallstones which have suddenly entered
the intestine by ulceration above, or by other material which may have
collected in some sacculation or diverticulum, where it has received
more or less calcareous deposit and has grown by accretion until it
produces obstruction, either by occlusion or by causing the intestine
to kink. Other foreign bodies may also produce obstruction. Although it
has been generally held that whatever may escape through the pylorus
may be evacuated from the rectum, nevertheless peculiarly shaped
objects become entangled in such a way as to be checked in progress and
serve as impacted bodies upon which an accumulation may take place.
(See Plate L.)
9. =Peritonitis.=--While coprostasis is a feature of almost every case
of acute peritonitis the obstruction referred to in this paragraph
comes rather from the adhesion and fixation of bowel from outpour of
lymph than from paralysis and ileus in consequence. It may be doubted
whether acute peritonitis is ever idiopathic. As seen by the surgeon,
at least, it has some point of origin which furnishes ample excuse
for its existence. The most common cause in the male is the appendix,
and in the female the appendix or the tube. At least one-half of the
cases occurring in general practice originate in one or the other of
these ways. Infection may also easily spread from the mesenteric nodes,
beginning locally and resulting in adhesions, the disease spreading
by a natural process until perhaps the whole abdomen is finally
involved. While healthy bowel is ordinarily impervious to germs, when
it becomes diseased germs may easily travel from its interior to its
exterior and thus set up peritonitis. In this way a purely mechanical
original condition may bring about a fatal septic peritonitis. It is
known also that intestinal diverticula are subject to exactly the same
lesions as is that one in particular which is called the appendix, and
the symptoms and sequences of the diverticulitis may simulate those
of an acute appendicitis. In acute appendicitis coprostasis and even
apparently fatal obstruction are frequently met with. Their occurrence
is to be explained not alone by toxemic paralysis (_i. e._, toxemic
ileus), but by the actual mechanical impediments offered by loops
of bowel strongly bound together around the appendix in the actual
protective effort.
10. =Bands.=--Bands of tissue which may cause obstruction of the
bowel are neither necessarily long nor large, and one will frequently
be astonished to see how trifling a tissue cord may produce intense
disturbance. The bands which may be found within the abdominal cavity
under these circumstances include those produced by peritoneal
adhesions, where the cohering lymph has organized and at the same
time stretched, such bands being found to arise from and connect
with the bowels alone, to arise from the omentum from any other
causes, particularly traumatic, or to occur at any point within the
peritoneal cavity. They may be single or multiple. When speaking of
Meckel’s diverticulum it was stated how it might be mistaken for a band
extending to the region of the umbilicus, and acting as one cause
of obstruction. (See Fig. 559.) An adherent appendix or tube tightly
attached at its free extremity may also act as a band, and the former
is known to very frequently produce at least a mild form of intestinal
obstruction, which may at any time assume acute proportions. The
pedicle of an ovarian or other tumor may also, if long, by becoming
twisted, include an intestinal loop and thus produce obstruction.
11. =Slits and Apertures.=--The mesentery is the occasional site
of fenestra which apparently are of congenital origin. Through
such openings or slits a loop of bowel may easily pass and become
strangulated. The same is true of the omentum. Openings in either of
these structures are perhaps more frequently the result of traumatisms.
Similar conditions result where omental or mesenteric surfaces have
united over small areas, leaving pockets or openings in which bowel
might be caught. Quite a similar condition results in so-called hernia
of bowel into and through the foramen of Winslow.
12. =Intestinal Loops and their Traction Effects.=--These causes
are not perhaps independent of some of those above mentioned, yet
presuppose a certain looping or abnormal festooning of intestine, with
the further stretching that occurs as the result of greater loading
and the final entanglement of such loops, or their adhesion, in such
a way as to become completely occluded. To this result some local
inflammatory process may contribute. The condition is often met in
connection with pelvic disease of females. Much that may happen to
a loop of bowel which has become attached to a growing tumor during
its migration, as it gradually changes its shape and position, may be
imagined.
[Illustration: FIG. 562
Strangulation of bowel by a long diverticulum. (Lejars.)]
13. =Congenital Defects.=--Certain congenital defects predispose to
acute obstruction. Among these are diverticula, as already mentioned,
which may produce trouble, either by incomplete obliteration and
separation from the umbilicus, in which event they act as bands or
cords, or by becoming acutely inflamed, then attaching themselves and
indirectly producing the same effects (Figs. 559 and 562). Even the
smaller diverticula or sacculations which extend between the folds
of the mesentery may, when infected and inflamed, thicken and cause
angular bending of the intestine, with consequent partial obstruction,
which later is made complete by the consequences of local peritonitis,
with its dense inevitable adhesions. Statistics show that acquired
diverticula occur twice as often as Meckel’s, and nearly as frequently
in the small as in the large intestine. They are mostly of the traction
variety and occur at the mesenteric border, where they have close
relation to the bloodvessels, thus increasing the dangers of operative
measures because of possible gangrene from shutting off circulation.
Porter has recently collected 188 cases of violent and even fatal
trouble thus produced within the abdominal cavity, returning an
exceedingly high death-rate after operation, which unfortunately was
almost always done late. In nearly all of these cases the diverticula
were found within the lower four feet of the ileum. In one case of my
own an unobliterated hypogastric artery caused acute obstruction.
14. =Postoperative Obstruction.=--Finally cases of postoperative
obstruction are met with in a way to bring disappointment and disaster
when everything else has seemed favorable, and constitute a clinical
type without any distinct pathological foundation. Most of them are due
either to some form of paralytic ileus, or else to local or general
peritonitis with its combined sequels of paralysis and adhesion by
the gluing of portions covered with exudate. Some of these cases
will justify reopening the abdomen, while in others the condition is
absolutely helpless because of the septic element present.
=General Symptoms of Acute Intestinal Obstruction.=--Certain symptoms
and signs characterize all cases of acute intestinal obstruction and
may be, therefore, included as common to each; consequently they may
be considered collectively. The cardinal indications are _pain_,
_vomiting_, _constipation_, _distention_, and _collapse_.
_Pain_ may be the first indication, and usually is so in invagination,
volvulus, and mechanical obstructions generally. It is usually of
violent paroxysmal character, continuing at least during the earlier
stages, rapidly wearing away the patient’s strength, diminishing as
distention increases and nerve endings become paralyzed.
_Vomiting_ is an early or late feature, according to the portion of the
alimentary canal obstructed. The more prompt its occurrence presumably
the higher in the small bowel the defect. In consequence of the
remedies usually administered it will be found that when nothing but
stomach contents are ejected it is easier to produce fecal evacuation
from below, while the greater the difficulty in securing a return from
the lower bowel the lower the obstruction and the more likely the
vomited material to become fecal in character. Vomiting once begun is
usually continuous until relief is afforded or the patient utterly
exhausted.
_Constipation_ or obstipation sooner or later characterize these cases.
The tenesmus of intussusception, with the passage of bloody mucus,
which may occur in this form, or in volvulus, for instance, does not
imply that the bowel itself is not obstructed, nor does the emptying
of the larger bowel of an accumulated load necessarily imply that
the fecal stream is in motion. Even the passage of flatus usually is
promptly shut off, and it is the gas which forms and cannot escape that
produces the distention.
_Distention_ gradually becomes excessive, the abdomen becoming
ballooned and extremely tympanitic on percussion, while its surface
becomes shiny because so stretched. This _meteorism_ is in large degree
due to the formation of gas within the bowel proper, but is permitted
by the additional features of paralysis of intestinal muscle and
weakening of that of the abdominal wall. As it increases the diaphragm
is pressed upward and respiration is much impeded, while even the
bladder may be compressed below. It affords another reason why fluid
which is taken into the stomach is quickly ejected.
Characteristic _collapse_ comes on more or less promptly, according to
the nature of the exciting cause, and the date of its occurrence is in
some degree an index of its violence.
In dealing with obstructive cases any history that may bear upon the
conditions, as of previous peritonitis, appendicitis, of so-called
dyspepsia which might indicate gallstone disease or gastric ulcer,
or of pelvic conditions which might indicate pyosalpinx or the like,
should be obtained. The manner of onset should be learned, whether
acute or gradual, with the relative date of the occurrence of pain,
vomiting, and stools, along with their character, if there be anything
distinctive therein. Past and present history being secured, the most
methodical examination of the body should be made, including the
physiognomy and general conditions, the attitude (_e. g._, whether the
knees are drawn up, whether the patient is able easily to turn), the
type of respiration, and the amount of restlessness. The character
of the abdominal movements during respiration should also be noted,
as well as the presence of any prominence or the indications of
violent peristalsis. By palpation the degree and location of greatest
tenderness, the presence of muscle spasm or of tumor may be learned.
_Careful examination of all the ordinary hernial outlets_ should be
made and the rectum and vagina explored. Revelations thus obtained may
also prompt a careful physical examination of the chest. Percussion
will show the presence of free or localized fluid or gas, while
localized dulness may denote a loop of intestine distended with fluid
or impacted feces. Auscultation will enable the surgeon to hear the
sounds produced by violent peristalsis or to note the absence of
movement within the bowel. A study of the temperature and the pulse
may reveal much in certain cases, especially the inflammatory, and
particularly in appendicitis, while the urine may be examined for
indican, and a differential blood count made.
_Meteorism, constipation, and fecal vomiting of themselves indicate
acute obstruction_, but furnish no aid as to the nature of the exciting
cause. They are, however, sufficient to indicate the wisdom of
immediate intervention.
Pathologically every case of intestinal obstruction has an interest of
its own. _Surgically, however_, they are readily grouped _as a class of
cases in which operation should always be performed early_, inasmuch
as it offers the better prospect of relief and in which death is the
inevitable spontaneous termination. It can scarcely be imagined how a
more distressing case than an acute strangulation can be allowed to
go to its fatal termination without being offered the prospect of a
judicious operation, if only performed early. The disfavor with which
operation is received by the general physician, as well as by laymen,
is due to the fact that too much time is wasted with futile drug
treatment, and that the golden hours when surgical intervention might
save are allowed to pass unutilized. Of most of these cases it may be
said that dying after operation they have died _in spite of it rather
than in consequence of it_.
This is particularly true with intussusception and volvulus in young
children or infants. Within six hours, in such cases, the harm which
may be done is necessarily fatal, and to keep them for a day or more,
dosing them with cathartics or making strenuous efforts to relax
invagination, is to deprive them of the only measure which offers them
any chance. The disrepute into which operative treatment of these cases
has fallen in certain quarters is due, then, solely to the fact that
the physician does not call the surgeon early, because there is a time
in the history of nearly every one of them when it could be saved were
mechanical relief afforded.
=Treatment.=--There are certain cases of obstruction by fecal impaction
or lodgement of enteroliths which may be successfully treated by
internal or non-operative means. Could these always be diagnosticated
it would be known when not to operate. But to wait until paralysis of
the bowel has occurred, or gangrene due to stasis, or perforation have
taken place, or septic peritonitis has set in, is to wait far longer
than circumstances justify and reflects on those responsible for the
delay rather than on the operator or the operation. In general terms,
_acute intestinal obstruction is always a surgical disease_.
It is not necessary to wait for accurate diagnosis--_recognition of the
existence of obstruction alone is all that is required_. Conditions
rapidly aggravate themselves, and strength is rapidly lost, if we wait
for more than distinctive symptoms. _There is no palliative treatment
save operation, and the drugs and other harsh measures which are often
prescribed serve to intensify and aggravate rather than to relieve._
Anodynes given, though administered with the most humane intent, serve
only to mask conditions and lead to delay.
Exploration once resolved upon, careful judgment must decide as to
where to place the incision. If local indications be present they may
be followed. If there be good reason to believe that the original cause
was an acute appendicitis, then the incision may be placed upon the
right side. In the absence of all indications the surgeon operates most
safely in the middle line by an incision below, above, or around the
umbilicus, as circumstances may indicate. Edema of the subserous tissue
or of the abdominal muscles indicates the presence of pus beneath.
Peritoneum should be sought and opened with care, as in the presence of
much distended bowel injury to the same may easily occur. The opening
once made the operator will be embarrassed from that time until the
conclusion of the operation by the distention of the bowels--at least
those above the obstruction, and by their being constantly in the
way. If a mechanical cause for obstruction be found it will be noted
that the intestine above is more distended than that below, which
latter may be collapsed and apparently smaller than natural. Thus if a
constricting band be found, or an internal hernia, the removal of the
obstructing cause will permit of prompt restoration of equal gaseous
pressure between the parts above and below.
Scarcely any surgical emergency requires wiser discretion than do
cases of this kind. Bands may be double ligated and divided, kinks
straightened out, twists untwisted, invaginations withdrawn, if this
be possible by reasonable effort. On the other hand the surgeon should
be prepared to find bowel which has apparently lost its vitality or is
actually necrotic, either for a few inches or for several feet, and
he will soon realize that to leave such gangrenous masses within the
abdomen is to accomplish naught, while to remove them is to subject
the patient to a procedure longer and more severe than he can bear. He
must, then, decide whether to close the abdomen for form’s sake and let
the patient die a natural death, or whether to undertake the risk of
resection, or perhaps to leave a considerable portion of the intestinal
canal upon the outside of the body, opening it and establishing an
artificial anus in the hope that the sloughing portion may be cast
off, and that the artificial anus, having served its purpose, may be
subsequently closed by another operation. Such cases live, though not
very often. Here, perhaps as often as anywhere, can be seen the most
desperate expedient succeed and the most trifling measure fail.
Another question is what to do with distended and paralyzed intestine,
especially when it appears impossible to restore it to the abdominal
cavity. Paralyzed as it is, it is almost too much to hope that it
may recover its tone, and distended as it is, it is practically
unmanageable. To open it at one point would be to empty several loops,
at least of gas and probably of fluid fecal matter, all of which
will help. One cannot but reflect on the toxic nature of all fecal
matter so retained and feel that could it all be evacuated the patient
would, other things being equal, be in vastly better condition. And so
operators have often made openings, taking all possible precautions
to prevent contamination, and have not only evacuated a considerable
length of the intestinal canal, but, as suggested by Mixter and others,
have washed it out.
A more perfect method, however, of accomplishing this purpose has
been suggested by Monks, of Boston, in the use of a large glass tube,
from twenty to twenty-four inches in length, strong and with smooth
ends. He has shown how, an opening having been made, say just above
the obstruction, it is possible by manipulating the bowel with gauze
pads to draw it over the tube (as shown in Fig. 563), to an extent
of several feet, and to thus more completely evacuate it than could
be accomplished in any other way. Monks is undoubtedly entitled to
priority for this suggestion over Moynihan, who has elaborately figured
and described it. All in all this permits better management and more
complete effect than any other method. The bowel having been emptied,
the opening is closed by the usual double row of sutures and is then
easily dropped back into the abdominal cavity. Cases occur where this
procedure might be carried out at two different points, say above and
below the obstruction.
[Illustration: FIG. 563
Method of inserting a tube (through an enterostomy opening) a
considerable distance into the intestine by drawing the intestine
around it with the help of a piece of dry gauze. The tube used in this
case has a curved extremity, the opening being on the concavity of the
curve. It is shown entire at the lower left corner of the illustration.
The longer the abdominal incision and the longer the tube the greater
the length of intestine which may be drawn upon it and emptied of its
contents. (Monks.)]
What may be done with the obstruction produced by local and
septic peritonitis, such as is especially seen in acute cases of
cholecystitis, appendicitis, and pyosalpinx? Here the surgeon deals
not only with twisted, kinked, and obstructed bowel, tensely distended,
but with much infected lymph and perhaps a collection of pus and a
gangrenous appendix. Such a condition becomes appalling and every
such case should be dealt with upon its merits. Any collection of pus
should be evacuated and drained, and it must then be decided whether
to endeavor to withdraw entangled loops, disengage and straighten them
out, or to be content with an artificial anus for temporary purposes,
the latter often being the safer course, even though it may lead to
a tedious convalescence and the necessity for subsequent operation.
It might even be advisable to evacuate pus and remove a sloughing
appendix, if it were easily found, and then make an enterostomy,
opening at some other point, in order to keep the two procedures and
fields of activity quite distinct.
A case may occasionally be seen where the question of affording some
relief is paramount to every other consideration, and where, at
the same time, the patient’s condition is such as to make anything
extra-hazardous. I have saved life under conditions of this kind by
making a simple enterostomy under cocaine, the intent being only to
attach a loop of distended bowel to the parietal peritoneum and to open
it then or a little later, thus establishing an artificial anus. This
may be done with local cocaine anesthesia. I have even seen the fecal
fistula thus produced close spontaneously in the course of time, and,
while the exact character of the lesion was never known, have had the
satisfaction of thus saving a life which I believe would otherwise have
been lost.
One of the most unfortunate accidents that can occur during operation
for acute obstruction is to have the patient practically drown in
his own fecal vomit. This may occur either on the operating table or
soon after leaving it. The term implies simply this--that there is
regurgitation of fecal matter into the stomach, and that as this is
ejected by a patient in his unconscious condition he is not able to
prevent its aspiration into the trachea, with the occurrence of all
that essentially constitutes drowning. Even a few ounces of fluid
material drawn into the lungs, under these circumstances, would be
sufficient to cause asphyxia and death.
The accident is to be prevented not alone by _lavage_, both before
and at the conclusion of the operation, but by placing the patient
upon his side in such a way that any gush of fluid into the mouth may
escape from it and not be sucked into the lung. The amount of fluid
that may arise is sometimes astonishing. The introduction of harmless
fluid, under these circumstances, would be sufficient, but the entrance
into the lungs of a viscid, offensive, and septic fluid, even in small
quantity, would quickly serve to induce a septic pneumonia if nothing
else. The accident once having occurred, resuscitation is almost
impossible. Under the relaxation of anesthesia it may occur without
outcry and almost unsuspected, and with the patient on his back, death
may be determined even before the attendant has noticed anything
particularly wrong. To prevent this accident tubes have been devised
having balloons around them which can be inflated with air, to the
desired degree, and the esophagus thus be plugged.
Hence it will be seen that the surgeon should temper his measures
to the condition of the case, its exigencies and its surroundings.
Operation, therefore, may be exceedingly mild or exceedingly severe,
taxing the resources of the best-equipped clinic.
Strangulations recognized from surface indications are usually dealt
with according to standard indications. Those discovered only after
abdominal section are to be dealt with each on its merits.
CHRONIC OBSTRUCTION OF THE BOWEL.
The expressions of chronic obstruction are essentially those of acute,
in which they usually terminate, occurring meantime in milder degree.
Their causes are nowise different from those tabulated above.
=Symptoms.=--The symptoms of chronic obstruction are those of
intermittent colic, constipation, perhaps with local tenderness,
with change in shape of the abdomen due to the primary cause or to
intestinal distention, and in many instances with some characteristic
appearance or shape of the feces. Thus the stools are often loose, or
scybalous masses when removed by cathartics, and these are followed by
diarrheal stools containing many gaseous bubbles. Obstruction of the
lower bowel will frequently cause the hardened fecal masses to assume
a tape-like shape. With increasing obstruction there is increasing
severity of symptoms, until finally they become acute.
=Treatment.=--The treatment of chronic obstruction is also operative,
either radical or palliative. When the exciting cause can not only be
detected on exploration but removed, it should be radical. If, however,
this be not possible then enterostomy or entero-anastomosis only can be
practised. Thus in cancer of the rectum or sigmoid, colostomy is the
last resort. In cancer of the bowel above the sigmoid anastomosis may
relieve the obstruction and permit the patient to linger until he dies
of the natural progress of the disease.
Here, as elsewhere, operation should not be too long delayed. To wait
for a chronic obstruction to merge into one of the acute forms, and
then to wait until the patient is moribund, is to have deliberately
deprived him of that which otherwise might have prolonged his life.
For chronic obstruction whose cause is not easily revealed the
hypothesis of cancer affords the most common explanation. This may be
intrinsic or extrinsic, so far as the bowel itself is concerned, the
results however not differing. It matters but little whether cancer is
producing an annular stricture or involving a considerable extent of
bowel, something should be done. When health has gradually failed, and
obstructive symptoms have come on slowly, and when distinct cachexia
is present the presence of cancer within the abdomen may be suspected.
When a distinct tumor is palpable or when the abdomen gradually
fills with fluid there is little doubt. When to these signs is added
_pigmentation of the abdominal wall_ the diagnosis may be considered
certain. Even now exploratory section is justified, in the hope that
some operative measure may offer comfort and at least temporary relief.
On the other hand, when obstructive symptoms appear and increase
without the accompaniment of other serious indications, it may be
hoped that the condition is benign rather than malignant. Obstruction
with ascites may possibly be due to _tuberculous_ lesions, which are
not uncommon, especially in children. The recognition of enlarged
mesenteric nodes would corroborate this diagnosis. A history of typhoid
fever or of injuries or foreign bodies might confirm the theory of
cicatricial stenosis. The possibility of enteroptosis of the colon and
impaction of hardened fecal matters should not be disregarded and that
of enteroliths, especially gallstones, not forgotten.
FECAL FISTULA; ARTIFICIAL ANUS.
A fecal fistula implies any communication between the intestinal tract
and the exterior of the body or one of its other cavities. Thus it is
possible to have a _rectovaginal_ fistula as well as a vesicovaginal.
In rare instances we may meet also with intestinal communication with
the bladder, the other viscera, or even the pleura or lungs.
Fecal fistulas are always abnormal productions, and result either from
congenital causes, previous injury, or disease. Among the traumatic
causes may be mentioned penetrations or ruptures of the intestines,
injuries to the bowel occurring in the course of abdominal operations
(for instance, the inclusion of some part of the bowel wall within
a ligature or suture), while the pathological causes include the
possibilities of perforation of any form of ulcerative lesion,
cancer, actinomycosis, or the secondary sloughing which may follow
appendicitis, or even the pressure of a drainage tube. Fistulas
result also from escape of foreign bodes (for instance enteroliths or
bone fragments), which may work their way into some other viscus, or
out through the abdominal wall to the body surface. Old pelvic and
abdominal abscesses also occasionally cause perforation and fecal
fistulas. These fistulous tracts may be long or short, and direct or
indirect. They may also permit the escape of a large amount of fecal
matter or the smallest appreciable amount. The majority of them tend to
close spontaneously in the course of time, but this time is sometimes
so prolonged that a surgical operation is preferable to waiting for
natural processes. The communications may be high in the intestinal
canal. In such a case matter that escapes will be but partially
digested and will have the character of chyme rather than of feces;
and patients suffer in consequence, as products of digestion are not
complete and opportunities for absorption have been too limited, and
they are deprived of all that should normally happen further along in
the bowel. In such a case there is temptation to operate much earlier
than is advisable. Another form of fistula results from certain cases
of strangulated hernia, in consequence of necrosis of the strangulated
loop of bowel. In fact this is true of any of the mechanical causes
of acute obstruction, where this expedient may be resorted to under
compulsion and we produce a fistula as an emergency measure.
The difference between intestinal or fecal fistula and artificial anus
is that the former is an undesirable and untoward event, whereas the
latter is deliberately produced by operation practised for the purpose.
_Artificial anus_ is in the main limited to cases of cancerous or other
hopeless or inoperable obstruction of the lower bowel, and in such case
is purely a palliative measure. It is made occasionally at the upper
end of the colon in order to give a diseased colon physiological rest
and permit of more perfect irrigation of that tube, the intent being
to later close the opening. It is an inevitable emergency measure
in certain cases of acute obstruction, where the patient is in no
condition to bear anything more extensive or prolonged.
The operation for making an artificial anus, usually referred to as
_enterostomy_ or _colostomy_, will be described below.
Fecal fistulas should be treated largely according to their causes;
when they are the product of actinomycotic or cancerous disease little
can be done, and perhaps nothing should be. On the other hand, when
resulting from traumatism, from sloughing of some portion of the bowel,
or from strangulation, much can be accomplished.
A small, fistulous tract should be kept clean and stimulated
occasionally with silver nitrate or something of the kind, and perhaps
by introducing into it every day a small piece of gauze, which
provokes the granulation process as well as fills the opening. It
is bad practice, however, to simply close the outer end and let the
lower portion distend with feces. Much will depend upon whether it now
connects with the bowel. This may be determined by injecting into the
fistula some methyl blue and then noting the subsequent stools. When
communication with the bowel is evidently free the surgeon may feel
like making a deeper operation, perhaps with intestinal suture or even
intestinal resection, whereas if there be little or no actual fecal
leakage it may be sufficient to enlarge the outer end of the fistula,
to thoroughly scrape it with the sharp spoon, and then, lightly packing
it, see it close with granulations. A passage-way which is exceedingly
short may be treated by simple superficial plastic operation, including
freshening of the entire margin of the opening and the passage around
it, and a purse-string suture, with or without a circular incision of
the skin. By drawing this suture tight the external opening may be
closed. This is a neat way in which to dispose of a small fistulous
opening resulting from a previous enterostomy or appendicitis operation.
A _rectovaginal fistula_ may be closed by formal operation, similar to
that for closure of a _vesicovaginal fistula_, based upon the simple
principle of freshening the edges of the opening and then holding them
together with suitably placed sutures. A rectovesical fistula would, in
most instances at least, require a laparotomy, with careful separation
of the rectum from the bladder, and then a separate suture of each
opening. Such an operation might be quite difficult, made so not by
its plan of performance but by the conditions which necessitated it.
Any bladder thus attacked should be kept perfectly empty for several
days by the use of a self-retaining catheter. Every case of fecal
communication with any large abscess cavity, or through the diaphragm,
directly or indirectly, as with a bronchus, should be treated on its
individual merits, it being a grave question whether operation would be
indicated or not.
Certain fecal fistulas will justify more formidable operation, in
which, after opening the abdomen and carefully protecting its contents
against contamination, the adhesions should be separated entirely and
that portion of the bowel which is involved removed, making either
an end-to-end suture or a lateral approximation. If this be done it
will be best also to completely excise the old fistulous tract through
the abdominal wall, and to remove everything that was involved in the
previous condition.
It is possible to atone for almost every opening of this character,
save those produced by some seriously malignant disease. If such a
condition be the result of cancerous extension then it is practically
hopeless.
OPERATIONS UPON THE INTESTINE.
=Intestinal Suture.=--Intestinal suture is by no means a new or modern
operation. It was spoken of by the ancient writers and was evidently
practised in the middle ages by the “Four Masters” of the School of
Salernum and their followers. But until it was reduced to a science
by the French surgeons, Jobert and Lembert, during the first quarter
of the past century, it was always a hazardous measure. Success with
intestinal suture depends upon exact hemostasis of the edges to be
united and their accurate approximation in layers (_i. e._, mucosa
to mucosa and serous and muscular coat to its like). Save when haste
compels, this accurate application is effected by two distinct suture
rows, the first or deeper (of hardened gut) made to include the mucosa
alone, the suture being usually continuous, but knotted at intervals,
with stitches close together and drawn tightly to amply secure against
leakage from the relatively large vessels of this membrane. It is
better to apply this row by itself, as any suture drawn through the
mucosa and out again through the serous coat is liable to contaminate
the latter, it being much better to keep the contaminated row of
sutures distinct. The first row having been applied and the surface
carefully cleansed the operator may then coapt the balance of the
annular wound by a continuous row of fine silk sutures, made to include
the serous and muscular coats and to avoid the mucosa. The stomach and
the colon are sufficiently thick to take a row of rather coarse sutures
for this purpose, but most of the small intestine is so thin-walled
that these need to be applied with caution as well as with dexterity.
Every row of sutures should be so applied and directed that the lumen
of the bowel be not reduced by its presence, it being a serious matter
to greatly encroach upon the diameter of the bowel, since obstruction
will thereby be favored and extra tension made upon the sutures (Figs.
564 and 565).
[Illustration: FIG. 564
Application of the interrupted Lembert suture. (Richardson.)]
[Illustration: FIG. 565
The continuous Lembert stitch. (Richardson.)]
So many different forms of intestinal suture have been devised that it
is useless to attempt here to describe them all.
Any minute puncture of the bowel may be closed by purse-string suture.
Any perforating wound should be not only first carefully cleansed, but
also slightly enlarged, cutting away its more or less contused margins
in order that fresh, viable tissue may be exposed. This is particularly
true of gunshot wounds. Many of the operations now practised include
inversion of the end of the bowel, a method illustrated in Fig. 566,
showing a method equally applicable to burying the stump after removing
the appendix, closing the end of a portion of the small or even the
large bowel.
Most operators now use for the mucosa a carefully prepared and
reliable chromicized catgut, the smaller size being preferable, with
the ends cut short after the knots are tied. It is well also to use
for intestinal suture needles which are round rather than made with
cutting edges, as by the latter openings are made larger and vessels
sometimes cut, this requiring the insertion of extra sutures for their
securement. Whether the operator shall use curved or straight needles,
and shall do the work with his fingers or depend upon various forms of
needle holders, is purely a matter of choice and training. _Success or
failure depend not so much upon the needle holder as upon the holder
of the needle_, and his care and attention to detail. In the presence
of multiple lesions the procedure may have to be repeated to meet each
indication.
=Anastomotic Operations.=--For the general application of the principle
of anastomosis to intestinal work the profession is largely indebted to
Senn. The principle having been once recognized will never be rejected,
but methods have already varied much from those first introduced, and
will be improved by the substitution of simpler procedures for the more
complex.
In general an anastomotic opening may be made between any distinct
portions of the alimentary canal, and almost any one part may be thus,
as it were, connected up with any other. Gastrojejunostomy has already
been described. Only under compulsion does one thus connect the stomach
with any other part of the alimentary canal. From the jejunum down to
the rectum one may, however, effect attachments of this kind at any
desired point. These operations are in the main done for one of the
following purposes:
(_a_) In cases of obstruction of the bowel;
(_b_) For the purpose of exclusion of a certain length; or
(_c_) As a substitute for end-to-end reunion, after resection of a
portion of the bowel.
The method of performance will depend not so much upon the nature of
the difficulty requiring the operation as upon the condition of the
patient, the equipment, and the operative skill of the surgeon. With a
patient in extremely serious condition that method which may be most
quickly performed is obviously the best. When time and method are under
control, then that is best which can be most perfectly performed by
the operator, or that which he is compelled to adopt, as when, for
instance, he resorts to a suture method because he has no button at
hand.
In order to simplify the subject as much as possible the following
methods alone will be mentioned here:
The _method by suture_ is essentially similar to that described as
gastro-anastomosis, the surfaces which are to be brought together being
properly placed, and approximated, first, by a row of silk suture, the
openings being then made with excision of a strip of mucosa, and the
mucosa being next sutured with chromic gut, first on the further side,
then on the near side of the opening, after which the serous membranes
are accurately sutured around the opening by continuation of the first
row of silk sutures. The actual opening made for the purpose should
be at least an inch in length, preferably an inch and a half or more,
while when the lower bowel is attached to the colon such an opening
may well have a length of at least 2¹⁄₂ inches, for if successful it
will be followed by a certain degree of cicatricial contraction and
will never remain of its original size (Figs. 566, 567, 568 and 569).
The suture may be combined with the _elastic ligature_, the method
again being similar to that for uniting the jejunum with the stomach,
already described. The rubber ligature used for the purpose is of the
same size, and there is no difference to be made in the directions
already given. The elastic ligature, however, can not be relied upon
in emergency cases where it is necessary to effect a communication at
once. It is serviceable only in instances where there is a leeway of
at least three or four days. This method has for one of its advantages
the fact that in its performance it is not necessary to clamp or secure
the bowel by any instrument, simply to empty it for the moment with
the fingers, it not being opened during the operation by anything save
the needle puncture, which is promptly filled with the rubber. It
does require, however, that the rubber used for the purpose shall be
reliable and new, it being unfortunately the case that pure rubber
which will last for a long time is seldom found in the market.
[Illustration: FIG. 566
Entero-anastomosis of intestinal loops which have been resected and the
bowel ends closed; the first row of sutures has been applied and the
line of opening indicated. (Lejars.)]
[Illustration: FIG. 567
Suture of the distal edges of the mucosa.]
[Illustration: FIG. 568
Insertion of the last (fourth) row of sutures. (Lejars.)]
[Illustration: FIG. 569
Resection of intestine with lateral anastomosis. Posterior suture
inserted. The free ends of the bowel inverted and sutured.
(Richardson.)]
The button method depends for its success upon a mechanical device of
Murphy, known everywhere as the “_Murphy button_,” or upon one of its
modifications. Fig. 570 illustrates the component parts of this device,
which is made in various sizes and, in fact, in various shapes for
different purposes, though the circular forms suffice for practically
all cases. In Fig. 572 it is seen in actual use, while Figs. 573 and
574 illustrate the method of its insertion and securement.
[Illustration: FIG. 570
The Murphy button.]
[Illustration: FIG. 571
End-to-end union of intestine by means of the Murphy button: the
two portions of the Murphy button, held in position by purse-string
sutures, are ready to be pressed together. (Richardson.)]
[Illustration: FIG. 572
Union--end to end--with the Murphy button.]
The underlying principle of the Murphy button is that each half can be
inserted separately and that then, by pressing these halves together,
an opening is at once afforded from one part of the bowel to the other.
If the halves be pressed together with the proper degree of firmness
they produce, first, adhesion between considerable areas around their
circumference, followed in the course of a few days by a necrosis of
the central portion, which sloughs because deprived of its circulation
by the pressure. So soon as this separation or sloughing is complete
the button drops into the intestinal canal, being completely loosened,
and is now carried along by peristalsis and by the fecal current from
above, its position shifting as would that of a scybalous mass or a
fecal concretion, until it finally emerges from the intestinal tube,
being passed from the anus. How soon it will thus appear will depend in
large measure upon the point of the intestinal canal into which it is
thus intruded. If this be high up it will be slower in appearing. If
low down it may be expected sooner. While it usually appears within ten
days or two weeks it may, however, be longer retained, and in one case
of my own was not passed for three months, although the anastomosis
was made with the ascending colon, into which it must have dropped.
Fig. 573 shows one of the halves held in the grasp of a forceps, being
inserted into a small buttonhole opening just large enough to receive
it, around which there has been passed a buttonhole or purse-string
suture of silk. This portion once thus inserted should not be lost
within the bowel, it being necessary to retain control of it by the
forceps until its application to the other half. Both halves being
inserted and brought opposite to each other, as in Fig. 574, the
smaller is introduced into the larger, and they are then pressed
together until the included serous surfaces are brought into contact,
with sufficient pressure inflicted to bleach them, in order that their
subsequent necrosis may be ensured. A circular row of sutures should
now be placed around the surfaces thus applied, in order to more widely
secure them in contact. The procedure being completed in this way, the
parts are dropped back into the abdomen and the abdominal wound closed.
[Illustration: FIG. 573
Introduction of one-half of a Murphy button. (Bergmann.)]
[Illustration: FIG. 574
Intestinal anastomosis with a Murphy button, showing the halves in
position ready to be pushed together. (Bergmann.)]
_End-to-end reunion_ can be accomplished by the same method, or the end
of the small intestine may be applied to the side of the large, after a
method which will be best understood by reference to Fig. 571, it being
necessary here to draw the squarely cut end of the intestine around the
button with a circular suture, and, at the same time, to so grasp the
button that it shall not recede into and be lost in the bowel.
Small buttons have been made for the purpose of uniting the
gall-bladder to the upper bowel and extra large ones are made for the
large intestine.
The particular advantage of the button method is the shortness of the
time required for its performance, as it can be conducted in a few
moments by one who might take four times as many minutes in using
sutures. The disadvantages attaching to it are these: (1) That it
depends for its success upon necrosis, _i. e._, of the part of the
bowel included within its grasp; (2) that it might itself serve as a
foreign body and produce acute obstruction, a not unknown event; (3)
that it is not always at hand, especially in emergency cases, and that
to rely upon it is to be limited in one’s abilities.
There is but little question that, when properly performed, the simple
suture methods are the best of all, and the operator who has never seen
a button used should abstain from its use. Still it has given many good
results. My belief is that the better the surgeon’s judgment, and the
more developed his skill, the less he will rely upon any mechanical
expedient of this character, and the more upon what he can accomplish
with the needle in his own fingers.
_End-to-side anastomosis_ is in no essential respect different from
resection, only it may be done for the purpose of exclusion when
nothing is absolutely removed. Thus in case of cancer of the cecum a
lateral implantation can be made of a lower loop of the ileum upon
the side of the ascending colon, using for this purpose a button,
having divided the ileum on the proximal side of the ileocecal valve,
and turned in both ends and invaginated the stumps. Here one resects
nothing, but makes a direct communication between the bowel above
and below the cancer, short-circuiting the intestinal canal, as
electricians would say, and all for the purpose of giving temporary
relief. Thus end-to-side or end-to-end anastomosis may be made,
according as circumstances dictate, and, if one chooses, with the
Murphy button.
_Resection of some portion of the large or small intestine_ is
required under a variety of different circumstances. Thus after
certain injuries, contusion and rupture, or numerous punctures or
gunshot perforations, it may be decided to remove a considerable
length of bowel rather than be compelled to give special attention to
a number of distinct lesions, believing it a time-saving measure, and,
therefore, for the welfare of the individual. The same measure will be
indicated when, either by injury or disease, the blood supply of any
portion of the bowel is apparently compromised or certainly shut off.
Here necrosis is so certainly to be expected, or perhaps has already
occurred, in such a way as to necessitate removal of whatever length of
bowel may thus be involved. Several of those cases, already mentioned,
which produce obstruction of the bowel will demand resection, as,
for instance, when reduction of an invagination is impossible,
with gangrene threatening. In a few instances extensive gangrene,
precipitated by embolism or thrombosis of the mesenteric vessels, has
been successfully treated by resection of considerable lengths of
bowel. Again, the bowel is resected for closure of fecal fistula or
artificial anus, as well as for relief of stricture due to various
causes. Finally, nearly all of the tumors of the intestine itself,
and especially all of the malignant forms, will require removal of at
least a few inches of gut, save in those cases where this is shown to
be impracticable because of the presence of cancer elsewhere, in which
case it may be sufficient to make an anastomosis.
When intestinal resection is not an emergency measure there should be
as much preparation as the case will permit, including lavage of the
stomach, the ingestion of sterilized food, the use of antiseptics and
the most thorough emptying of the bowel which can be accomplished.[58]
[58] Sanderson has suggested a new method of sterilization of the
interior of the bowel at the time of operation. He injects a solution
of acetozone through a hypodermic needle, or, after opening the
bowel, freely irrigates with the same.
One of the greatest difficulties attendant upon the operation is the
avoidance of all contamination by contact of peritoneum with intestinal
contents. Against this the most minute precautions should be taken.
This is never an easy matter, and in the presence of distended bowels
and the emergency of acute obstruction it sometimes taxes every
resource at hand. A variety of clamps have been devised by different
operators, the intent being to so clasp the bowel beneath their blades
as to completely occlude it. These blades are covered with sterilized
rubber tubing to keep them from acting too harshly, and it is necessary
to use pressure upon the handles with great discretion, lest permanent
injury be done to the bloodvessels. The bloodvessels of the bowel are
essentially terminal, and the blood supply should be kept sufficient
for every part which is not removed. These vessels are, moreover,
numerous and relatively large, and hemorrhage is not always easy of
control, especially when clamps are not at hand. As a substitute for
clamps tapes of sterilized gauze may be used, being tied around the
bowel, or the fingers of a reliable assistant may be substituted. Such
use of the fingers is not easy nor simple, not only because they become
tired and relax their grasp, but since they slip so easily, and because
the escape of one drop of fecal matter may cause a fatal contamination.
Resection of the bowel may imply in one case a removal of but two or
three inches of its length, while the other extreme is not reached
until several feet of bowel have been removed. I have been able to
successfully remove eight feet and nine inches of intestine, the lower
part including the cecum and a portion of the ascending colon, and
there are now on record nearly twenty cases where over 200 Cm. of
bowel have been resected, nearly all of them recovering. Success in
this procedure depends partly upon the condition necessitating the
operation, as well as the general condition of the patient, but in no
small measure hangs upon the perfection of the operator’s technique.
[Illustration: FIG. 575
End-to-end or circular anastomosis by enterorrhaphy. First row of
distal sutures in serosa. (Type of needle differs from that used in
this country). (Lejars.)]
[Illustration: FIG. 576
Completion of last row of sutures, begun as shown in Fig. 575.
(Lejars.)]
Whatever be the condition which requires such resection it should be
made sufficiently extensive to completely include and permit the total
removal of the diseased or injured portion. The abdominal incision
should be large enough to permit the delivery upon the surface of
the body of all that portion to be removed. Unless this be done the
difficulties are greatly enhanced. Save where there is some distinct
indication for opening elsewhere, this incision is made in the middle
line. The compromised bowel having been sought and thus delivered and
one having decided exactly where to divide it, clamps are so placed
both above and below each line of division as to prevent leakage.
Underneath the bowel to be thus divided gauze is placed in such a way
as to receive the small amount of discharge which will escape from the
portion between the clamps. The exposed bowel surfaces should then
be thoroughly cleaned, the contaminated gauze removed, fresh pieces
substituted for it, and the other division of bowel made in the same
way. While in some cases it may be well to tie off the mesenteric
border and secure all its vessels before dividing the bowel, this may
at other times be delayed until after the division. At all events it
is the next step. Whether the mesentery shall be simply separated
along the intestinal border and tied off in small portions, one
after another, or whether a triangular resection of a portion of the
mesentery itself should be made, securing the larger vessels nearer to
its root, will depend on the nature of the case and upon whether the
mesentery itself be involved in the disease. In dealing with cancer
it is often necessary to remove, at the same time, every enlarged
lymphatic. It may be inferred that no incision or tear, no matter
how short, can be made in these tissues without danger of subsequent
hemorrhage unless the parts be secured against it. A series of
ligatures and sutures is therefore called for here which may consume
no small proportion of the entire time of the operation. (See Figs. 575
and 576.)
All that portion of bowel which has been condemned having been removed
and a careful toilet of the parts having been made the surgeon next
proceeds to restore the bowel lumen. A V-shaped defect in the mesentery
should be united with sutures. The line of former mesenteric border
left after removal of bowel should be not only carefully protected with
ligatures, but the whole margin should be overcast and so folded in
or drawn together in tucks as to make it easy to bring the bowel ends
together without undue stress.
[Illustration: FIG. 577
FIG. 578
Circular anastomosis of portions of the bowel having different lumina.
(Bergmann.)]
The sutures by which the divided bowel is restored should begin at the
mesenteric border, and every care should be taken to make the joint at
this point absolutely water-tight. Suture methods have been described.
To unite bowel ends of the same diameter it is an easy matter to suture
together first the mucosa and then the outer layer, so long as the
intestine is on the outside of the body and equally accessible on all
sides (Fig. 578). The surgeon is sometimes compelled to do this work
within the body cavity, as in resection of the rectum for cancer. It
may be advisable to first place a row of sutures between the serosa
and muscularis on the further side of the margins to be united, then
to close the mucosa completely around, and then to finish the outer
layer of sutures. So long as differences of size are not conspicuous,
end-to-end approximation can be made almost anywhere. When, however,
it is necessary to attach small bowel to large, the size of the larger
opening should be reduced to fit the smaller, or one or both ends
may be closed, turning in the stump, as already described, and then
making lateral or end-to-side anastomosis. Any such anastomotic opening
should be so placed, and bowel so directed, that there shall be no
interference in the direction of the natural bowel stream, failure to
observe this precaution producing not only added immediate danger but
more or less permanent obstruction (Figs. 579 and 580).
[Illustration: FIG. 579
Isoperistaltic lateral apposition.]
[Illustration: FIG. 580
Antiperistaltic lateral apposition (bad).]
All that has been said above with regard to the Murphy button and its
use in anastomotic operations holds equally good here with regard to
its usefulness after resection.
Numerous devices, either instruments for the purpose of holding the
bowel together while it is sutured, or of affording substitutes for the
Murphy button, have been planned by operators all over the world. There
are few of them, however, which give any better results than the simple
methods above described, to which I prefer to limit description here
because of their very simplicity.
Intestinal suture or any other method of completing the resection
having been finished, a careful toilet of all exposed parts should be
made, by which bowel may be dropped back into the abdominal cavity and
the latter closed without drainage.
The _subsequent management_ of these cases will consist in two or
three days’ starvation, in order that peristalsis may be reduced to a
minimum, the patient being meanwhile fed by the rectum. Then will come
a time when both fluid food, and cathartics a little later, should be
gently and discriminately administered. Any satisfactory suture method
will rarely give way after forty-eight hours. Buttons, on the contrary,
may break loose after many days or even weeks, and this fact affords
another argument against their use.
[Illustration: FIG. 581
Enterostomy; preliminary fixation of a loop of bowel to the peritoneum.
(Lejars.)]
[Illustration: FIG. 582
Enterostomy; fixation of margins of opened gut to skin. (Lejars.)]
=Enterostomy.=--Enterostomy for establishment of fecal fistula, or
_artificial anus_, is performed for relief purposes and sometimes as
an emergency measure. It consists in attaching some portion of the
bowel, naturally that above the constriction or disease which compels
the operation, to the parietal peritoneum through a small wound in the
abdominal wall. When the large intestine is opened for this purpose the
operation is usually referred to as a _colostomy_, and this preferably
is done in the left iliac region. When enterostomy of the smaller bowel
is preferable it may be done at any point on the abdominal surface.
Thus if through a median incision a condition be found necessitating it
the bowel should be attached at the lower end of the abdominal opening,
for here drainage will be better and contamination less likely. When
enterostomy is done for acute obstruction, it is preferable to place
the opening in one iliac fossa or the other.
Enterostomy consists essentially of the following steps: opening
through the abdomen, recognition of the parietal peritoneum, which
is seized with forceps on either side, opened and secured with these
forceps, after which the first tensely distended loop of bowel which
presents is taken, and, with a series of fine sutures in a round
needle, the serous surface of the gut is attached to the margins of the
parietal peritoneum (Figs. 581 and 582). In the more desperate cases
a portion of the bowel may be brought out through the wound and fixed
there in such a way that it cannot recede. If the emergency is great
the bowel may be immediately punctured, the patient so placed and so
protected that fecal contents shall escape away from the body rather
than over it. If one can take a little time he may wait a few hours
for the adhesion which is sure to take place between the peritoneal
surfaces and the consequent shutting off of the abdominal cavity from
the outer wound. Thus after twelve hours the surface of bowel exposed
through the wound may be punctured either with a knife, scissors, or
the actual cautery, and this may be done without causing pain to the
patient. Escape of bowel contents will instantly ensue after puncture.
After permitting all to escape that will, abundant protection should be
provided for the reception of the discharges, which will continue at
reduced rate. The best way to do this is to pass into the bowel in the
proper direction a rubber tube, as large as it can accommodate, or a
glass tube, bent at an angle, which shall connect with a flexible tube,
and thus conduct away all discharge.
Another method of performing the operation is to bring out the loop of
bowel, open and empty it, then to introduce a glass or rubber tube,
around which is snugly fastened the bowel margin. The intestine is
then stitched in place and the tube so arranged as to conduct away all
discharge.
Just how much may be expected of such a relief opening will depend upon
the case. These operations, especially for cancer of the rectum or the
lower bowel, may prolong life for two or three years. An emergency
opening into the small bowel for relief of acute obstruction may need
to be kept open for but a few days, after which the tube may be removed
and the fecal fistula be allowed gradually to contract. According to
the case an intestinal resection may be made or the opening may be
closed by one of the plastic methods.
=Appendicostomy.=--Appendicostomy is the more complete form of carrying
out a suggestion first made by Hale White, of opening the colon on
the right side in cases of intractable colitis. Gibson suggested to
accomplish this by a method similar to Kader’s for gastrostomy, making
a valvular colostomy through which the colon might be irrigated,
without escape of feces. In 1902, Weir, intending to do this operation,
found the appendix rising so invitingly into the wound that the
inspiration occurred to him, and was promptly acted upon, to utilize it
for the purpose.
In performing the operation the smallest possible incision should be
made through which the appendix may be delivered, its mesenteric artery
is tied, and its mesentery stripped down to its origin. At the latter
the cecum is fastened to the parietal peritoneum by a suture on either
side, avoiding the appendicular artery itself. The balance of the wound
is then closed as usual, the appendix being fastened to the lower angle
by suture, the protruding part then wrapped with gutta-percha tissue
and included in the dressing. At the end of two days the external
portion may be divided about 1 to 4 inches from the skin, after which
a catheter is passed along its lumen and the stump tied around it.
This serves the double purpose of preventing leakage and severing the
appendix flush with the skin. The catheter is introduced from 2 to 4
inches, and its external portion left open to allow escape of gas, or
doubled and fastened to prevent leakage, as circumstances may require.
Irrigation may be begun on the third or fourth day.
When the appendix is used for the purpose of forming an artificial anus
it will be probably in instances where there is more of the emergency
element present, and it may be sufficient then to simply utilize it for
the purpose of anchoring the cecum to the abdominal wall, or with the
purpose of dilating it after the expiration of a few hours. In other
words, the method may be modified to meet the indication.
It is scarcely necessary to devote space to any other operative
procedures upon the small intestine. Consequently it will simply
be mentioned here that the upper part of the jejunum can be used
for artificial feeding and _jejunostomy_ made to take the place of
gastrostomy under those rare circumstances which may demand it.
Upon the large intestine _colopexy_ may be practised, attaching it
to the anterior abdominal wall or to the border of the liver or the
gastrohepatic omentum. Andrews’ suggestion to attach the colon to
the lower border of the liver, after certain operations upon the
biliary passages, will be described in connection with the latter.
In cases of extreme dilatation, with loss of muscular tone, etc.,
involving especially the colon, an _enteroplication_ may be practised
corresponding to gastroplication, and having the same purpose, with a
technique practically identical with the other. Thus when the sigmoid
flexure is so dilated as to largely fill the abdominal cavity, with an
enormous S-shape, much can be done by thus reducing its dimensions,
the only objection being the fear that the causes which produced the
condition will conspire to reproduce it even after enteroplication.
CHAPTER XLIX.
THE APPENDIX AND ITS DISEASES.[59]
[59] The laity, as well as part of the profession, having not
yet ceased to wonder at the great importance attaching today to
appendicitis, when twenty years ago it was practically unknown, it is
worth while to insert here the following brief historical account:
The term “appendicitis” was coined by Fitz for a condition which
had not been hitherto unknown, but to which he gave a classical
description. That the appendix might be primarily diseased had
been known for one hundred and fifty years; that peri-appendicular
abscesses were frequent may be seen by reference to works of the
middle and latter part of the past century on perityphlitis and
perityphlitic abscess, Willard Parker, of New York, being the most
prominent writer of his day upon this subject. In the _Transactions
of the Medical Society of the State of New York_ for 1875, Gouley
reports a case of so-called perityphlitic abscess due to perforation
of the appendix, with remarks upon its surgical treatment. The
curious feature attaching to this case was that two years previous
to its occurrence the patient had swallowed one of his teeth.
Although this tooth was not found at the time Gouley alluded to the
possibility of it or any other small body lodging in the appendix and
finally causing ulceration. He referred also to the case published
in 1856 by Dr. Lewis, of New York, who reported an individual dying
at the age of eighty-eight, whose appendix was found to contain
one hundred and twenty-two deer shot, it appearing that he had
been exceedingly fond of game; he supposed that the shot found in
the appendix were contained in meat which he had eaten. Lewis also
referred to forty-seven cases of foreign bodies which he tabulated,
all but one of which died.
Fitz’s article appeared in 1886. In it he claimed that operation
should be done much earlier than was then the custom, and he showed
that 34 per cent. of these cases died during the first five days
of illness. But the first real operation for appendicitis as such
was done by Krönlein, of Zurich, according to a suggestion made by
Mikulicz in 1884. The second was done by Symonds, in England, in
1885, this being an interval operation. The first operation in the
United States was done by Hall, of New York, in May, 1886, although
to Morton, of Philadelphia, the credit must be given of the first
operation in this country on a case deliberately diagnosticated. This
was in April, 1887, Sands doing the next one in December of the same
year.
McBurney had assisted Sands in a large number of cases, and in 1889
published his classical paper with an account of “The First Recorded
Case where an Acutely Inflamed Appendix had been Removed while Full
of Pus.” In the same year Weir also published an elaborate paper,
making similar recommendations. It is not necessary to follow the
subject later than the year 1889, since to it every surgeon of note
has probably contributed.
=Anatomy.=--The vermiform appendix is an embryonic relic, and, like all
such remains, is not merely superfluous, but often troublesome. That
at some time it may have had an ordinary function is not to be denied;
that now, in quadrupeds at least, it has one cannot be successfully
maintained. Its past importance may, however, be perhaps indicated by
the fact that in the ostrich, for instance, it is said to assume a
length of six feet. Because of its relatively wide variations in size,
length, and emplacement, as well as because of its mesenteric and
other anatomical arrangements, its affections are often complicated
and variable in the symptoms they produce. The appendix is, in fact,
a miniature intestinal tube, having the same structure as the small
intestine, though but greatly reduced. Its average length should be 8
to 9 Cm., the shortest on record being 1 Cm., and the longest perhaps
24 Cm. Its average gross diameter should be that of a No. 16 French
catheter, but it may be found 1.5 Cm. in size. The average diameter of
its lumen should be 1 to 3 Mm. The appendicular artery is given off
from the right colic branch of the ileocolic artery, and it ordinarily
divides into four or five branches, according to the length of the
appendix and the extent of its mesentery. It derives its nerve supply
from the superior mesenteric plexus of the sympathetic ganglia, which
itself is connected with the right pneumogastric, this fact explaining
many of the reflexes accompanying its diseases. In it lymph abounds and
lymph follicles are numerous. Around its neck, as around the origin of
every other embryonic canal (as Sutton has shown), is found a _collar
of lymphoid tissue_ corresponding in structure to that seen in the
pharynx. This tissue is inflammable, and succumbs easily to infection.
Hence probably the apparent ease with which infection and gangrene
occur in this locality. The position of the appendix is variable, and
depends in effect on the development of the cecum and the degree of
its rotation during this process. Its most frequent location (40 per
cent.) is behind the cecum. In 30 per cent. of cases it occurs on
its anterior surface or just at its lower end. It may lie as a free
pouch with a loose mesentery, movable in the abdominal cavity, or it
may be essentially a retroperitoneal affair not only not free, but
even difficult to find. In direction it may vary correspondingly.
Thus it may lie behind the colon, perhaps pointing straight upward
toward the liver; it may hang in the pelvis, it may point toward the
sacrum, or it may coil up anteriorly; and, according to the extent and
freedom of its mesentery, in any of these locations, it may either be
unattached and movable or quite bound down. Again, it may lie nearly
straight or it may be kinked, bent, or coiled. It is necessary that
the surgeon appreciate these possible variations, for they account
for vagaries in symptomatology. In brief it should lie in the iliac
fossa, at least, and to the outer side of the iliac vessels, but it
may hang over into the pelvis in 20 to 25 per cent. of cases, or its
tip may rest in a pocket or even in a subcecal fossa. In other words,
it may be found in almost any attitude or position, these variations
being explainable by peculiarities of fetal development. Furthermore
it may even have its own _diverticula_, as has been recently shown.
Normally it should be practically empty, save perhaps for a little
muddy mucus. Very frequently, however, it contains fecal matter, and
upon this fact depends much of its importance. If from retained fecal
matter fecal concretions gradually result, then these become irritants
and may produce either appendicular colic or may predispose to acute
infection. Upon the retention of fecal contents should depend also a
miniature peristalsis, and imitation of what goes on in the intestine
above, in the production of a genuine appendicular colic. How annoying,
painful, or even disabling this may be may be learned from the history
of many a patient. On the other hand the appendix may become gradually
occluded or obliterated, in whole or in part. If this process begin
at its distal end and involve the entire tube it might be considered
a fortunate occurrence for the patient. If, however, it be due to
previous inflammation, or to subinvolution of the previous process,
and if fecal concretions be thus imprisoned, it is hardly desirable
and will frequently lead to trouble. More or less occlusion occurs in
probably at least one-fourth of mankind.
Like the bowel above, the appendix may suffer in various as well
as in similar ways. Thus in it may be seen pathological conditions
which involve the bowel proper. Tuberculosis and actinomycosis may
even occur here as apparently primary lesions, while cysts have been
discovered within its walls, and such tumors as fibromyomas or primary
adenocarcinomas are also met here. I have seen three or four instances
of primary cancer of the appendix, and have now living one patient from
whom six years ago I removed an appendix and adjoining portion of the
cecum involved in most distinct cancer.
Again, the appendix participates in certain hernias and has been found
in instances of strangulated or non-strangulated inguinal and femoral
hernia, and has been seen also in cases of umbilical hernia. Twice I
have found it in the inguinal canal and once in the femoral.
Furthermore when diseased the appendix, like the bowel, may contract
adhesions to certain viscera, while it is now well known that it may
attach itself to the kidney, the bladder, the right ovary, the tubes,
or the uterus. This is of more than mere passing interest, for by such
adhesions cases are not only surgically complicated, but diagnosis is
made difficult, because of associated symptoms pointing to the organ
thus involved.
=Foreign Bodies in the Appendix.=--Foreign bodies are occasionally
found. This expression refers not merely to the fecal concretions
above mentioned, which are practically small enteroliths. Thus, Kelly
has mentioned cases in which ordinary pins have been found in this
location, two of these cases being my own. In one instance I found the
appendix to contain a round-worm at least three inches in length, and
other intestinal parasites have been found by other observers. The
laity have been greatly impressed by the reputed frequency with which
grape and other seeds are found in the appendix, these figuring in
their eyes as exciting causes of disease. In truth seeds are seldom
found, that which has been mistaken for them being fecal concretions of
various sizes and degrees of density. I have found actual seeds two or
three times, but probably not oftener.
=Bacteriology of Appendicitis.=--Acute appendicitis being essentially
an acute infection one inquires naturally which are the organisms most
commonly involved. Answer to this question should be sought rather
in the text-books on pathology, and should be summarized here by
simply saying that the colon bacillus is perhaps more often found in
connection with these cases than any other one organism. Streptococci
and staphylococci rank perhaps next in frequency, while the
pneumococcus, the capsule coccus, and all of the other pyogenic forms
may be present, either as contaminations or in almost pure cultures.
The fauna and flora of the intestinal tract afford ample opportunities
for contaminations with many forms of microbes. If pus found here be a
pure culture of any one organism it is most often of the colon variety,
which is known to vary much in virulence, even when occurring alone.
Mixed infections, however, are more predominant and more serious,
especially in proportion as the more active pyogenic organisms appear
in greater numbers. The bacteriology of appendicitis is then of great
pathological interest, but concerns the surgeon very slightly, unless
he have to do with some peculiar form, such as pyocyaneus, or a
particularly virulent streptococcus.
[Illustration: PLATE LI
Illustrating Various Degrees of Involvement of Appendix Vermiformis.
(Richardson.)
_A._ Chronic, recurring.
_B._ Chronic, much thickened.
_C._ Acute, with necrosis and rupture.
_D._ Showing necrosis of mucous membrane.
_E._ Gangrene and perforation, permitting fecal extravasation.
_F._ Total gangrene without perforation.]
=Appendicular Colic.=--Sufficient has been said above regarding the
appendix as a miniature intestine, its outlet guarded by the little
valve of Gerlach, to afford an anatomical reason why conditions even
in the larger bowel should be imitated here. Some writers have not
placed as much stress upon appendicular colic as I would here. One
sees many instances of it if he will only recognize it, the frequency
of its occurrence not only disturbing the comfort of patients, but
keeping ever before their minds the necessity for operation. An
absolutely empty appendix will be free from all abnormal activity
of this kind, but when a little fecal matter has become imprisoned,
and when by its long retention fecal concretions have formed, they
may give rise to considerable disturbance without actually producing
inflammation, the former being due to the spontaneous effort of the
appendix to expel them. This effort may be excited by other conditions
in the bowel adjoining, but by itself it may be the essentially
relatively violent muscular effort which produces pain and is followed
by soreness. That not a few cases of acute appendicitis commence with
an appendicular colic is extremely probable, and that it may occur
at frequent intervals and never pass the colicky stage is equally
true. _Appendicular colic, then, may be a precursor of an infectious
appendicitis, acting as a predisposing cause, or either may occur
independently of the other._
Indications of this form of colic are frequent, viz., nagging pains in
the region of the cecum, which may last a few moments or a few hours
and then subside, leaving a tenderness which persists for a day or
two, after which the patient seems to be free for a longer or shorter
interval, to suffer again and again in the same way. These attacks may
be accompanied by some nausea, will be found frequently associated with
whatever may have disturbed ordinary intestinal activity, and may even
produce a mild degree of fever, which latter is partly due to mental
perturbation and partly to a mild degree of toxemia, the latter being
possible in connection with abnormal appendicular activity, as the
_appendix itself is a closed sac_ and the very materials which it is
trying to expel may furnish the toxins.
It is difficult to distinguish between appendicular colic and mild
attacks of catarrhal appendicitis. The transitory nature of the former
is its particular diagnostic feature, coupled with absence of all
lasting indications.
The following would seem the simplest working classification of lesions
of the appendix.
{Catarrhal. Endo-appendicitis.
{
{Diffuse. Parietal or {Hyperplastic.
{ interstitial. {Obliterative.
{
_A._ Acute. { {Intertubular.
{Purulent. {Intramural.
{ {Peri-appendicular.
{ Any of these may lead to
{Gangrenous or
{Perforative lesions.
_B._ Subacute. Recurrent or relapsing.
_C._ Adhesive or obliterative.
Almost any of the above forms may be associated with diseases of
other abdominal viscera, as, for example, with typhoid. Thus out of
119 autopsies on typhoid patients 19 showed changes in the appendix
corresponding to those produced by the typhoid organisms in other
portions of the intestines. (Kelly.) Of 3770 autopsies on tuberculous
patients tuberculous lesions were noted in the appendix in 44
instances. The appendix may also become involved with any form of
ileocolitis, either in the young or in the adult. Again an infection of
the right tube and ovary may easily extend to and involve the appendix,
just as infection may travel in the opposite direction. (See Plate LI.)
Before discussing the causes of this condition it is advisable to
take a comprehensive view of the entire subject in its pathological
relations. As Dieulafoy has shown, appendicitis is the consequence
of the transformation of the hollow conduit into a closed cavity,
whose length and narrowness make it liable to such changes, for
which various causes are to be assigned: for example, the formation
of calculi or concretions which are quite comparable to renal or
biliary and which lead to a true appendicular lithiasis. There is even
reason to believe that a calculous appendicitis may be hereditary and
belong to the patrimony of gout. At other times it is the consequence
of local infection, followed by tumefaction, and corresponding to
obstruction of the Eustachian or the Fallopian tubes. Again it results
from slow, progressive fibrous alterations or from the strangulations
due to twisting or formation of adhesions. In any event the closed
cavity varies in size and shape, and does not necessarily lead to
self-destruction unless the bacteria thus pent up are sufficiently
virulent. At all events the attack declares itself only when the cavity
is actually closed, and it is then that imprisoned bacteria, previously
harmless, multiply and intensify their virulence, as they do in a
blocked loop of bowel. At times an acute intoxication from toxins is
produced, and may be so pronounced that patients succumb to it almost
before the characteristic lesions, or any local peritonitis, has become
fairly outlined. On the other hand if retained bacteria be but slightly
virulent, or have been successfully conquered by phagocytes, or if the
canal has become pervious again, the attack may spontaneously subside,
although there is great probability of recurrence. In many instances
the infection ends in ulceration, abscess, gangrene or perforation,
all of which may give rise to peritonitis of varying extent and
severity. Germs may traverse the walls of an affected appendix without
perforation. It may then become the direct cause of peritonitis,
septicemia, or hepatic abscess.
=Recurrent Appendicitis.=--_Every attack of appendicitis, no matter
how mild, predisposes to a repetition of the trouble, in mild or in
fulminating form._ Every appendix once inflamed has had its blood
supply compromised and may break down easily upon a second attack.
While not every patient who has once suffered in this way should
necessarily suffer again, the majority who have had one attack may
have another. No one can be prophetic in this regard and no one may
truly assert that several mild attacks may not be followed by another
most severe. That an appendix has been once inflamed is sufficient
to justify its subsequent removal. That it has been several times
involved makes operation next to imperative. Even repeated attacks
of appendicular colic predispose to trouble in this region. In any
appendix which has in this way frequently excited suspicion, or which
gives rise to frequently recurring though mild colicky pain and local
tenderness, especially when coupled with mild stercoremia, indications
are for removal. It may be safely laid down, then, as a rule, to
which there should be few exceptions, that _any appendix which causes
frequently recurring or almost continuous trouble should be removed_.
=Causes.=--It is impossible in any brief summary to include all the
possible causes of appendicitis. Those mentioned below are perhaps
those most commonly recognized or pronounced, yet the list is far from
complete. First of all it should be remembered that the disease occurs
in a vestigial organ, containing relatively considerable lymphoid
tissue, especially around its neck, that it is comparatively poorly
supplied with blood, and that such tissue under such circumstances
inflames easily and breaks down quickly. Doubtless the trouble in some
instances commences within the tiny intestinal tube. At other times its
originating cause lies without, as, for instance, when its blood supply
is interfered with by pressure of an overloaded cecum, by tumors,
or by violent intestinal activity; this especially in connection
with an appendix firmly anchored and not freely movable, it being
so fixed in many instances that it cannot readjust itself easily to
varying conditions. Thus an overloaded cecum may first press upon the
appendix and then by violence of activity so displace it that it may
easily succumb. Again in those appendices which hang downward into the
pelvis there is little or no drainage by gravity, and they may easily
become overloaded. A movable kidney may also disturb the integrity of
an appendix in certain locations. Foreign bodies frequently excite
pernicious activity, especially fecal concretions, and actual calculi
or miniature enteroliths. Traumatism sustains a certain relation to
some cases of violent activity of the psoas muscles in athletes, which
may upset the circulation of appendices which lie directly upon the
muscles involved.
Many of the causes mentioned above are predisposing rather than actual.
The actual exciting causes of acute infection have mainly to do with
_germ activity_ and with _vascular supply_. It is well known that the
more virulent the organisms the more acute the resulting inflammation,
and it is also well known that colon bacilli and the ordinary pyogenic
organisms vary in virulence within wide limits, and that mixed are
often more acute than simple infections. Typhoid bacilli, tuberculous
bacilli and the like vary in the same way, and, in company with other
germs, may easily light up serious disturbance.
=Complications.=--Of the complications which may accompany or ensue
upon appendicitis the most common are those which involve the
peritoneum, either local or general. Acute peritonitis is to be
feared not only because of its autotoxic expressions, but because
of the acute obstruction which it may produce by gluing intestinal
loops together and paralyzing their motility. When to more or less
widespread peritonitis are added general sepsis, with all its possible
complications, and such further local expressions as cellulitis, which
may be pericolic, subphrenic, perineal, or pelvic, or phlebitis which,
involving the portal system, would soon lead to formation of hepatic
abscess, it will be seen how easily the case may become serious.
Furthermore not only may the ovary and tube suffer, but cystitis
and nephritis may occur as toxic complications, while finally, by
violence of the ulcerative process, a fecal fistula may form. This is
by no means a complete list, but includes some of the more frequent
complications.
=Symptoms of Acute Appendicitis.=--_Pain with nausea, tenderness_, and
_rigidity_ constitute the triad of the most indicative early signs and
symptoms, each of which needs to be considered by itself.
=Pain.=--Pain is at the same time an important yet variable feature. In
few other acute lesions does it vary as much in degree and location.
Generally it is referred at first to the more central portion of the
abdomen, as around the navel or between it and the right side of the
pelvis. Later it may be localized at some widely distant point, as,
for instance, far over upon the left side. Such vagaries may be held
to be due to peculiarities of emplacement of the appendix, and would
indicate that the organ will probably not be found in its most common
location, but rather extending to the left or hanging over into the
pelvis. When the appendix is attached to or lies near the bladder there
may be considerable pain in the pelvis and in the bladder. It should be
remembered that the parietal peritoneum is much more sensitive than the
visceral, and in proportion as the lesion approaches the surface more
exact information may be gathered from location of pain. Occasionally
it may be referred to the region of the gall-bladder, or even to the
chest above the diaphragm. In some instances it is agonizing, almost
from the outset; in others it is never very severe. The rapidity
of the process may be measured to some extent by the intensity and
character of the pain. When the disease resolves slowly and kindly pain
_gradually_ subsides, but the _sudden_ subsidence of pain, especially
without equal improvement in other respects, is a _bad_ rather than a
good sign, indicating probably that perforation has occurred.
=Tenderness.=--Tenderness is a more constant and persistent and,
therefore, a more reliable indication than pain, and, as well, less
misleading. No matter where the patient may seem to feel pain the
actual tenderness will indicate the location of the appendix itself.
Thus even if pain on the left side be severe, tenderness will not
accompany it, but will be found centred at the location of the
appendix. This is a fact of great importance. In his first paper on
appendicitis McBurney showed that the appendix is most commonly located
at a point beneath a line drawn from the umbilicus to the anterior
superior spine and one and a half or two inches away from the latter.
This has since been known as McBurney’s point. To it, however, too much
importance should not be attached, since the appendix is often not
found under this area, and tenderness may be found at a distance two
or three inches away from it. Over the actually tender area the skin
will also be hypersensitive, and this intense hyperesthesia is also an
indication of considerable value.
=Rigidity and Muscle Spasm.=--Rigidity and muscle spasm are to be
carefully studied, and upon them much reliance may be placed. With
the first onset of pain they may be general, but they usually become
more and more localized, unilateral, and finally limited, save in
those instances where general peritonitis has begun and is spreading.
For instance, Richardson regards it in this light: “Rigidity with
distinctly localized pain strongly suggests appendicitis; with fever
it almost proves it; with tumor it fully establishes diagnosis.” When
to ordinary abdominal rigidity is added actual muscle spasm, provoked
by even light palpation, and occurring in the rectus or one of the flat
muscles lying in close relation to the appendix, then a still more
important indication has been obtained. When true muscle spasm involves
all the abdominal musculature general peritonitis has probably begun.
=Tumor.=--The presence of tumor in the suspected area will nearly
always be a corroborative sign, but diagnosis should not depend upon
its presence. It is hardly to be looked for during the early hours or
perhaps days of an ordinary attack. It may be due to fecal impaction
in the cecum, to outpour of exudate, to binding together of omentum
and intestine, or to the presence of pus. If a considerable mass can
be detected within the cecum during the early hours of an attack
this should be regarded rather as an expression of coprostasis and
impaction, to which the attack itself may be due. Tumor, therefore, is
significant when present, while in some instances its absence is still
more so.
=Vomiting.=--Vomiting is an irregular and uncertain feature. Probably
the majority of cases begin with nausea (after the initial pain) or
with vomiting, either one without the other, or with both combined.
Likely through the course of the disease vomiting may be an occasional
disturbing element, though patients may have no nausea whatever.
=Bowels.=--The condition of the bowels and their behavior will depend
very much upon their actual state at the moment of attack. Some attacks
seem precipitated by violent intestinal activity; here diarrhea or
dysentery will be an early feature. Others are precipitated rather
by overloading of the cecum; in these cases constipation would be a
well-marked feature. Bowel inactivity is to some extent an expression
of bowel paralysis due to toxemia, which in some instances is profound,
in others slight.
=Temperature.=--The temperature is also a variable and uncertain
feature. It may be normal at first or very high. At any time it may
rise gradually or suddenly, and may subside in the same atypical way.
Taken by itself it is an unreliable feature. When, however, temperature
steadily rises the surgeon may take alarm, and if the pulse rate goes
up correspondingly the case takes on a serious aspect. A sudden fall of
temperature is almost as serious a feature as a sudden rise. A normal
or subnormal temperature may be seen when a large amount of pus is
present, or but a minimum of disturbance may be found when operating
upon a patient whose temperature is 104°.
=The Pulse.=--The pulse is a more reliable guide than any obtained with
the thermometer, its rapidity being proportionate to the gravity of
the disturbance. _A constantly rising pulse is a serious indication_,
especially if accompanied by vagaries of temperature. Some operators
regard the pulse as a sufficient indication for operation, holding
that when it rises above 112 operation should be made. I hold this to
be a good rule, but would not have it interpreted as indicating that
operation should not be done unless the pulse attains this figure, and
believe that, no matter what the other conditions, the final indication
has arrived when the pulse goes above 112.
=Abdominal Distention.=--Abdominal distention may be due to gas
formation, to constipation, or may indicate the paralysis of
peristalsis. When it becomes well marked it is a serious indication,
and when toxemia is profound no sound whatever will be heard within
the bowels thus distended. It usually indicates the onset of general
peritonitis. It is unfortunate in more than one respect, since
intra-abdominal conditions are masked by it and operation complicated,
it being sometimes impossible to restore the bowel to the abdomen
without at least partially emptying it.
=Jaundice.=--Jaundice, when occurring, is a toxic expression, possibly
due to temporary obstruction of distended or paralyzed bowels.
Finally the _general appearance_ of the patient will be suggestive,
patients with serious conditions having always an anxious or haggard
facial expression, rarely moving themselves easily or freely in
bed, or smiling at anyone or anything, their faces being perhaps
somewhat flushed, their expression and action being apathetic, while
perhaps later there will be delirium with restlessness. When the face
is pinched, the eyes sunken, the nose sharp, the skin dusky, and
respirations rapid and unsatisfying, as well as of thoracic type, any
intra-abdominal infection may be regarded as serious and unpromising.
What shall be said about the _value of the blood count_? It is
possible in nearly every instance to make a diagnosis of appendicitis
without the aid of the microscope, as well as even to judge of the
advisability of immediate or postponed operation. Nevertheless an
indicative differential blood count, an affirmative result of the
iodine test, or the discovery of indican in the urine, may afford
positive corroboration in cases where doubt may have existed. In
reality, however, any case which will furnish satisfactory and distinct
responses to these tests should be recognized without them. A leukocyte
count above 12,000, in connection with other indications, is usually
sufficient to justify operation. A very high leukocytosis--_e. g._,
above 24,000--is a matter of great importance. In the more chronic
cases the leukocytosis is but slight.
=Diagnosis.=--Obvious and indicative as many cases of acute
appendicitis are from the outset, there are still others when one may
be in serious doubt, even for some days, either because patients do
not clearly state their own symptoms, because of peculiar reference of
pain, or because of the co-existence of complications, each of which
may mask the other.
_Colitis_ of adults and _enterocolitis_ of children will produce
sometimes severe attacks of pain, with cramps and local tenderness,
that may at first mislead. There is a form of _mucous colitis_ which is
now more generally recognized than in time past, in which diagnosis is
sometimes quite difficult. The onset is often sharp, while the right
iliac fossa may be occupied by an elongated, resistant, tender mass,
showing fecal impaction within the cecum. On the other hand the same
condition may be met in the left iliac fossa, and will thus indicate
that the sigmoid is especially at fault. In these conditions there is
often actual exudate around the inflamed bowel, and this may even break
down; it is proper then to speak of a _circumscribed colitis_, and
there is reason to think that in certain cases it arises from infection
of a diverticulum from the large bowel. The pain is not infrequently
complained of at the so-called McBurney point. In not a few instances
the appendix has been removed when under perfectly natural suspicion,
and found so slightly involved as to show that the actual trouble was
in the cecum rather than in the appendix itself. Dieulafoy believes,
in fact, that formerly the cecum was made too much of and the appendix
disregarded, while today these conditions are sometimes reversed.
From _gallstone disease and cholecystitis_ its symptoms are sometimes
quite difficult to distinguish. Especially is this true when pain is
not accurately localized, and when, on the other hand, muscle spasm and
tenderness are widespread. The previous history of the case will give
much aid in this matter, while the pain in gallstone trouble radiates
rather toward the right shoulder, in appendicular disease toward the
umbilicus or downward. When dulness on percussion shades directly into
liver dulness the gall-bladder is naturally the more to be suspected.
When patients themselves cannot make minute distinctions in description
of pain and tenderness the condition may be difficult of recognition.
=Peritonitis.=--_The majority of all attacks of so-called idiopathic
peritonitis spring from appendicular disease_, at first and perhaps
throughout unrecognized. A condition of peritonitis, then, for
which other explanation is not found may be considered as, in all
probability, due to appendicitis whose peculiar features may have
been masked. It is not difficult to recognize a condition of general
peritonitis. The great difficulty is to ascribe its proper cause. As
already and elsewhere indicated these conditions merge into expressions
of acute obstruction which still further complicate the case, and
it is by no means infrequent to have this order of events: an acute
gangrenous appendicitis followed by local peritonitis, with adhesions,
which, becoming dense, rapidly produce obstructive symptoms, the
condition going even farther and gangrene spreading from the appendix
proper to any or all of those intestinal loops which come in contact
with the primary focus, so that when the condition is thoroughly
revealed it is found to be one of multiple gangrene of the bowel as
well as of fierce and septic peritonitis.
_Gastric and intestinal ulcers with perforation_ are easily mistaken
for appendicitis, especially when the duodenum is involved. In at least
half of the recorded cases of perforating duodenal ulcer the condition
has been at least at one time supposed to be one of acute appendicitis,
while after perforation has occurred and the matter which has escaped
has worked its way down toward the right iliac fossa the similarity of
conditions will be all the more striking. If an accurate history can be
obtained there will probably be learned from it that which will tend to
avoid mistakes. The exceedingly abrupt and acute onset of symptoms will
also be more pronounced than in most cases of commencing appendicitis.
This is true also of the perforations of typhoid ulcer, especially
of “walking typhoid.” While acute appendicitis during the course of
typhoid is by no means unknown, the abrupt onset of pain, rigidity, and
tenderness during the third week or later would suggest perforation
very much more than the possibility of an appendical lesion.
_Acute obstruction of the bowel_ due to other causes than
appendicitis--_e. g._, volvulus or intussusception--might give rise to
symptoms which would be regarded as indicating appendicitis. This is
true also of _strangulated hernias_, especially the internal forms,
since there will be no excuse for failing to discover an external
strangulation of this kind. _Lead colic_ may simulate some of the
milder and more chronic forms of appendicitis, from which it should
not be difficult to exclude it by its history, the occupation of the
patient, and the appearance of the gums.
The _kidneys and ureters_ are sometimes so involved as to occasion
doubt. A _floating kidney_, with its possible crises, displaced into
the right iliac fossa, where it might be mistaken for an inflammatory
mass, might thus cause some hesitation. So also might the acutely
suppurative forms, the formation of a sudden phlegmon about the kidney,
or the entanglement of a calculus, either at the hilum or along the
ureter, produce severe pain, tenderness, and fever, which would at
first easily perplex. The pain of renal colic, however, is usually more
agonizing, beginning in the flanks and referred down along the ureters
to the genitals and the inner side of the thigh. It may also be intense
in the back, and may be accompanied by nausea and vomiting. Renal colic
is also nearly always accompanied by frequent urination and sometimes
by the appearance of blood in the urine. With an impacted calculus at
the lower end of the ureter at the level of the appendix diagnosis may
be very difficult. Here the _x_-rays may afford some assistance.
_Acute pancreatitis_ begins with intense abdominal pain that may at
first suggest appendicitis. The pain, however, is usually epigastric;
abdominal distention comes on early; vomiting may be profuse, and
the tenderness is most marked along the left costal border. There
is, moreover, a more profound prostration, sometimes accompanied by
cyanosis. An acute suppurative pancreatitis may soon be followed by
peritonitis, which when seen will so completely mask all symptoms that
diagnosis as between the two is quite impossible, but symptoms which
can be accurately localized will usually point to the upper rather than
to the lower abdomen.
_Mesenteric thrombosis and embolism_ are rare conditions which
commence usually with fulminating symptoms and produce intense agony,
with tenderness and rigidity all over the abdomen. Their onset is so
profound that patients fall into a condition of extreme collapse within
the first few hours, and their tendency is so rapidly to the bad that
they are not likely to be mistaken for acute appendicitis.
The _pelvic viscera of women_ also furnish acute inflammations, such
as _pyosalpinx_, with or without rupture, that sometimes precipitate
very acute symptoms which may point to the abdomen rather than to
the pelvis. In many of these instances the appendix is more or less
adherent to the adnexa on the right side, and infection in either
one may easily travel to the other, so that both become ultimately
involved. Local examination will reveal the existence of pelvic
conditions, in whose absence there may be justification for inferring
that the trouble has not originated in that cavity.
_Ruptured extra-uterine pregnancy_ has been in numerous cases mistaken
for acute appendicitis. It usually begins with violent pain and
pronounced muscle spasm, with more or less shock. I have repeatedly
been called to operate for appendicitis and found the other condition
present. The operator may be prepared to find it if he elicit a
suggestive history or if a vaginal examination reveals a pelvis more
or less filled with semisolid material. Amenorrhea does not always
signify ectopic gestation, yet when doubt arises it would be advisable
to inquire carefully into the menstrual habit of the patient. On the
other hand it is known that acute appendicitis may bring on uterine
hemorrhage. When, however, the possibility of pregnancy exists, along
with a history of menstrual irregularity, or of hemorrhages unaccounted
for, and one finds within the pelvis the uterus pushed forward or
displaced, or perhaps an irregular tumor, he may suspect the condition
if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis
occurring _during pregnancy_, or still worse, as I have seen it, _e.
g._, in a woman with a large uterine myoma, gone to about the seventh
month of pregnancy, and then suffering from an acute peri-appendicular
abscess, the whole proving more than she could withstand.
With an appendix placed behind the cecum it will usually rest upon the
psoas muscle, where it may be disturbed by violent exercise, or where
it may lead to mistaken diagnosis either in case of acute inflammation
of the muscle itself or of acute appendicitis. When the right limb is
drawn up, and especially when all motions of the limb give pain, we may
believe at least in the participation of the muscle in the inflammatory
activity. On the other hand, an insidious _psoas abscess_ may give
rise to a certain degree of tenderness in the right iliac fossa, with
flexion of the thigh, and gradual development of tumor, which may be
mistaken for chronic appendicitis.
The possibility of _appendicitis occurring during typhoid_ has been
mentioned. Differential diagnosis between the two conditions will
ordinarily not be difficult when one can obtain an accurate history.
In classical appendicitis pain is always the first symptom, and
temperature rarely rises until a number of hours at least after the
first attack of pain. Even the milder typhoid cases may show tenderness
in the right iliac fossa, but one should look for the characteristic
eruption and make a Widal test. The presence of splenic enlargement
would point to typhoid, as would also the occurrence of bronchitis,
epistaxis, or headache, with perhaps albuminuria. The most perplexing
cases will be those of _perforation_, perhaps even of typhoid ulcer
of the appendix. In these cases acute pain will usually indicate
perforation.
_Intrathoracic affections_ sometimes begin with or are accompanied by
severe pains which are referred to various parts of the abdomen and
cause great confusion. Thus I have repeatedly seen pneumonia, even
on the left side, regarded at least at first as acute appendicitis,
because patients referred most of their pain to the abdomen rather
than to the chest, while the abdominal muscles participated to such
an extent as to produce pronounced rigidity. Here a blood count
would scarcely help, but careful physical examination of the chest
would reveal the difficulty. _Such examinations should be made when
respirations become irregular, or when the breathing is evidently in
any way embarrassed._ Acute pneumonia and acute pleurisy, especially
diaphragmatic, may have then to be differentiated from acute
appendicitis.
Finally, _hysteria_ is an element not to be disregarded in some of
these cases; not that it is likely often, if ever, to lead to serious
doubt, but that patients with the hysterical or neurotic temperament
are constantly tempted to so seriously exaggerate their complaints
as to lead to at least a more serious view regarding themselves than
circumstances justify. Thus a mild appendicular colic in a neurotic
patient may produce a disproportionate complaint, and one must be ready
to assign to hyperesthesia or exaggerated complaints their proper value.
The _symptomatology of appendicitis_ may then be summarized briefly
as follows: When pain comes on suddenly and is referred to the lower
part of the abdomen, or even its central region, becoming perhaps
more localized as the hours go by, is shortly followed by nausea
or vomiting, and this by general abdominal sensitiveness, with an
increasing degree of rigidity; and when temperature, which at first
is not elevated, begins to rise in from twelve to twenty hours, then
it may be held that this is a classical picture of an attack of acute
appendicitis. So strongly does Murphy, for instance, hold to this order
of events that he even questions diagnosis when symptoms are not thus
timed, and especially if vomiting precede pain.
When pain which has been severe subsides, and comes on afresh after an
interval of perhaps thirty-six hours, it is to be regarded as due to
fresh peri-appendicular involvement, and is an unfavorable feature. _In
fact the subsidence of pain and apparent improvement often noted do not
always mean actual improvement, but may be the forerunners of a still
more dangerous condition._ Thus the “perilous calm” of appendicitis
should hasten operation, or at least increase watchfulness, rather than
beget confidence. Should one rely too much upon them and procrastinate
he will find that his mortality rate will rise accordingly. The
statement elsewhere quoted in this work that “the resources of surgery
are rarely successful when practised upon the dying,” will apply here.