"The Kraske Operation" is applied to various methods in which access to
the rectum is obtained by removing the coccyx or cutting off certain
portions of the lower end of the sacrum. They are all modifications of
Kraske's original method, with which we are all familiar. Dr. Tuttle has
modified this plan, as it furnishes a rapid and adequate approach to the
rectum; it facilitates the control of hemorrhage and restores the bony
floor of pelvis and attachment of the anal muscles, and involves injury
of the sacral nerves and lateral sacral arteries on one side only. The
technique which he employs is as follows:
The patient is previously prepared as heretofore described, and an
artificial anus established or not, as the conditions indicate; before
the final scrubbing the sphincter should be dilated and the rectum
irrigated with bichloride 1-2000 or hydrogen peroxide. It should then be
packed with absorbent gauze, so that the finger cannot be introduced.
The patient is then placed in the prone position on the left side, with
the hips elevated on a hard pillow or sandbag; an oblique incision is
made from the level of the third foramen on right side of sacrum down to
the tip of the coccyx, and extending half-way between this point and the
posterior margin of the anus.
This incision should be made boldly with one stroke through the skin,
muscles and ligaments into the cellular tissue posterior to the rectum;
the rectum is then rapidly separated by the fingers from the sacrum, and
the space thus formed and the wound should be firmly packed with sterile
gauze. A transverse incision down to the bone is then made at a level of
the 4th sacral foramen, the bone is rapidly chiseled off in this line,
and the triangular flap is pulled down to the left side and held by
retractor. At this point it is usually necessary to catch and tie the
right lateral and middle sacral arteries. Frequently these are the only
vessels that need to be tied during the entire operation, although if
one cuts too far away from the sacrum, the right sciatic may be severed.
The first step in the actual extirpation of the rectum consists in
isolating the organ below the level of the resected sacrum, so that a
ligature can be thrown around it, or a long clamp applied to control any
bleeding from its walls. If the neoplasm extends above this level and it
is necessary to open the peritoneal cavity to extirpate it, one should
do this at once, as it will be found much easier to dissect the rectum
out by following the course of the peritoneal folds. By opening the
peritoneum and incising its lateral folds close to the rectum, the
danger of wounding the ureters is greatly decreased and the gut is much
more easily dragged down.
When the posterior peritoneal folds or meso-rectum is reached, the
incision should be carried as far away from the rectum, or, rather, as
close to the sacrum, as possible in order to avoid wounding the superior
hemorrhoids artery, and to remove all the sacral glands. The gut should
be loosened and dragged down until its healthy portion easily reaches
the anus or healthy segment below the growth. A strong clamp should then
be placed upon the intestine about one inch above the neoplasm, but
should never be placed in the area involved by it; for in so doing the
friable walls may rupture and the contents of the intestine be poured
out into the wound. As soon as the gut has been sufficiently liberated
and dragged down, the peritoneal cavity should be cleansed by wiping
with dry sterilized gauze and closed by sutures which attach the
membrane to the gut. By this procedure the entire intraperitoneal part
of the operation is completed and this cavity closed before the
intestine is incised. After this is done the gut should be cut across
between two clamps or ligatures above the tumor, the ends being
cauterized with carbolic acid and covered with rubber protective tissue.
The lower segment containing the neoplasm may then be dissected from
above downward in an almost bloodless manner until the lowest portion is
reached. It is much more easily removed in this direction than from
below upward, and there is less danger of wounding the other pelvic
organs. If the neoplasm extends within one inch of the anus, it will be
necessary to remove the entire lower portion of the rectum. If, however,
more than one inch of perfectly healthy tissue remains below, this
should always be preserved. Having removed the neoplasm, if one inch or
more of healthy gut remains above anus, one should unite the proximal
and distal ends either by Murphy button or end-to-end suture.
All oozing is checked by hot compresses, and the concavity of the sacrum
is packed with a large mass of sterilized gauze, the end of which
protrudes from the lower angle of the wound. This serves to check the
oozing, and also furnishes a support to the bone-flap after it has been
restored to position. Finally the flap is fastened in its original
position by silk-worm gut sutures, which pass deeply through the skin
and periosternum on each side of the transverse incision. Suturing the
bone itself is not necessary. The lateral portion of the wound is closed
by similar sutures down to the level of the sacro-coccygeal
articulation; below this it is left open for drainage (Tuttle, Diseases
of Rectum, Page 829-1903).
REPORT OF A CASE OF GANGRENOUS
APPENDICITIS, FROM THE SERVICE
OF PROF. R. WINSLOW.
BY C. C. SMINK, '09,
_Senior Medical Student_.
In selecting a case I have not taken one that is a surgical curiosity,
or at all an unusual one, but I have taken this because it is just in
these cases that a doubt sometimes exists as to the treatment when
diagnosed, and often the condition of the appendix and surrounding
peritoneum is in doubt, even if a diagnosis of trouble originating in
the appendix is made.
_History of Case_--Patient, a boy, L. W., age 9 years, schoolboy;
admitted December 26, 1908, with a diagnosis of appendicitis.
_Family History_--Parents well; one brother died in infancy, cause
unknown; two brothers living and well; only history of any family
disease is tuberculosis in one uncle; no rheumatism, syphilis, gout,
haemophilia or other disease bearing on the case.
_Past History_--Measles at 5 years, with uneventful recovery;
whooping-cough at 6, no complications; badly burned two years ago; has
had "indigestion" (?) since he was 3 years old; pain but no tenderness
during these attacks; treated by different physicians and got better for
a time; no history of scarlet fever, influenza, pneumonia, typhoid or
other disease of childhood.
_Habits_--A normal child.
_Present Illness_--On 20th of December, 1908, patient came home from
church complaining of pains in the right side. This was Sunday. Next day
he complained of severe pain all over abdomen, but on Tuesday these
became localized in the right lower quadrant of the abdomen. Had some
fever. Bowels constipated. No nausea or vomiting. There was a localized
tenderness in the right lower quadrant from the start. Pains got better
on Friday, but temperature and pulse still stayed up, and patient came
into hospital on Saturday, December 26. The unusual feature was that
there was no nausea or vomiting. It is also to be noted that the pain
subsided suddenly on the 24th. The child entered hospital on the 26th,
and on entrance the whole right side was rigid, while the left side was
comparatively soft. A lump could be felt in the appendical region, the
centre of which was above McBurney's point. Temperature was 99 and pulse
78. The leucocyte count, however, was 30,200; urine negative.
Child was put to bed; an ice cap placed on the abdomen. Liquid diet. The
next day, December 27th, leucocytes stood at 35,200. Temperature
unchanged, but the pulse had risen to 110 beats. A hypodermic of
morphine and atropine was given, and patient taken to the operating
room, anesthetized, and abdomen cleaned for an aseptic (if possible)
operation.
Prof. Winslow made an incision in the abdominal wall, well out toward
the crest of the ilium, using the gridiron incision. The caecum was
found and pulled over toward the middle line, and in looking for the
appendix, which was supposed to be behind the caecum, a great quantity
of pus was found. This nasty smelling, grayish pus welled up into the
wound and was sponged away. Several pieces of mucous membrane and
presumably the tip of the appendix were found in the pus. Also several
faecal secretions. The pus was sponged away and carefully a search was
made for the appendix, or rather what remained of it. It was found tied
down by adhesions and dissected loose. It broke away in pieces, and it
was unnecessary to ligate any of the arteries of the meso appendix. The
stump of the appendix close to the caecum was crushed, cauterized and
ligated. No attempt was made to invert it, as the tissues would not
stand it. The pus cavity was found to extend up behind the caecum and
over toward the median line for some distance. The puncture, which I
will refer to later, was then made in the right lumbar region, and two
cigarette drains were introduced extending clear back into the bottom of
the abscess cavity. Then a gauze drain was introduced into the anterior
wound, and this sutured up. The wound was then dressed and the patient
taken to the ward. Recovery from anesthetic without ill effects.
The next morning the patient was unable to pass his water, and had to be
catheterized. Aside from this no ill effects were seen, and his
temperature and pulse remained practically at the same place. At the end
of 48 hours the drains and dressings were changed and the patient was
doing well and the wound draining profusely. At no time was the bed
elevated and at no time was a stimulant administered, with the exception
of a hot normal salt enema on the day following the operation. Several
times during his stay a dose of castor oil was given, but no other
medication was necessary. As the dressings were reapplied and drains
introduced daily the wounds were found to be granulating up, and
gradually these closed, first the one in the lumbar region and then the
one in the abdomen. By the tenth day a normal temperature was present,
and he sat up on the twelfth.
The child went on to an uneventful recovery, and went home on January
21st fully cured.
This was undoubtedly one of those cases of gangrenous appendicitis
where, owing either to the intensity of the infection or to a thrombosis
of the vessels supplying the appendix, the vitality of the tissues is
lost and gangrene results. Now, "even in this, the gravest form of
appendicitis, the general peritoneal cavity is often protected against
infection by walling off the pus, and the appendix, detached in the form
of a slough, is often found on opening the localized abscess." But "in
other cases there is from the beginning the symptoms of peritoneal
sepsis and peritonitis."
Now, it seems to me that a great deal depends on the kind of
infection--or, rather, the kind of organism infecting--and often the
difference between a localized abscess and a general peritonitis is
really the difference between a colon and a streptococcus infection.
Again, should a general peritonitis develop, I have noticed from a
number of cases in the wards that the prognosis practically depends on
the organism, although we all know that a general peritonitis is a
mighty grave condition, no matter what it is due to.
Another point in favor of the child was the fact that the gangrenous
process seemed to start in the tip of the appendix, and it seems that
when it starts there, there is greater likelihood of localization, and
when it starts in the base a greater likelihood of general peritonitis.
I said that there was often doubt as to the condition in the abdomen in
these cases. Now, there can be no doubt that the two main points in the
diagnosis of a localized abscess are tumor and an aggravation of the
symptoms present. But this case exemplified the fact that there may be
cases where there is no aggravation of symptoms, and in a great many
cases it may be impossible to feel the tumor until it has become very
large, owing to its situation, viz., post caecal. Even in this case,
from which a great quantity of pus was evacuated, there was no absolute
certainty of finding pus on opening the abdomen, although it was
suspected strongly.
I have seen a patient walk into the hospital on Sunday with a
temperature of 100 and a pulse of 99, and when the abdomen was opened on
Monday morning a most virulent form of general streptococcus peritonitis
was found, from which the patient died the next day. It is said that it
is much better to depend on the pulse and its variations than on the
temperature.
I would like to call attention to several points in the treatment of
this case also.
First, the place of incision was, as I said, well up towards the iliac
crest, and not in the time-honored McBurney point. The wisdom of this is
self-evident.
Second, the care used in not breaking up the wall of the abscess formed
by the peritoneum.
Also, the fact that the appendix was carefully dissected up and tied off
and allowed to heal by itself, obviating, as much as possible, the
danger of a faecal fistula. The older books advised evacuating the
abscess and leaving the appendix to slough off, and, while I have seen
seven cases where this method was used and not a single faecal fistula,
yet it seems to me the more rational treatment to remove the offender,
as I have also assisted in three operations where the appendix was
removed at the second operation. That is, an operation supposedly an
appendectomy was done, and later, at a subsequent period, the diseased
appendix was found still causing the same old trouble.
Again, the use of the lumbar puncture, so as to drain the abscess cavity
from its very bottom. I wonder this is not done oftener, as it appeals
to me as being a most sensible thing.
Then the abscess cavity was sponged out with gauze, and not washed out
with the antiseptic fluid that books advise, thus spreading bacteria all
over the peritoneal cavity, and really doing no good. Nature was allowed
to throw off such things as she deemed necessary, an avenue of escape
having been provided.
And, lastly, the omentum was found and brought down, covering in the
cavity as much as possible, and thus aiding in the walling off process.