Appendicitis. 431

Scott confirmed this observat ion. He found an equal n u m b e r of ]ymphocy tes and polynuclear leucocytes.

REFERENCES. La Pratique Dermatologique.

"-' Macleod. ttandbook of the Patholagy of the Skin. :~ E. Graham Little's Experiments. British Journal of Dermatol.

January, 1906. Brit. Jour. Dermat. VoI. XI. 1899.

5 Brit. Jour. Dermat. Oct., Nov., Dec., 1905; Jan., 1906. ~ Mallory and Wright. Patho]. Technique. 7 Pbysiolegict~l Histology. 51ann.

ART. XXIV. --Appendicitis.a By DE.~'Is •ENNEDY, F.I~.C.S.I. ; Surgeon, Je rv i s Street Hosp i ta l , Dubl in ; Surgeon, Chi ldren ' s Hosp i ta l , Dubl in .

~T is quite usual to read in surg ica l text -books and in medica l journa ls e laborate accounts of the indicat ions for opera t ion in appendici t is . The condi t ion of the pulse, the t empera tu re , and the tongue, the posi t ion of the ]~gs, and numerous other signs and symptoms are all enumera t ed to show when we should opera te ; and, usua l ly as a final touch to the pic ture , the wr i te r gives us a couple of special signs which, when present , ahvays make h i m recommend ~perat ive procedure. And all this fo rge t fu l of the fac t tha t no two cases run ml para l le l lines. I n consequence, we cannot, wonder tha t the o rd ina ry p rac t i t i one r is con- ~used as to the course he should adopt in these cases, and tha t there is a fixed idea in his mind tha t operat ion in appendic i t i s should be carr ied out only when the pa t ien t is on the br ink of the precipice, t ha t it is except iona l ly dangerous , and t ha t every effort should be made to br ing the pa t i en t to convalescence wi thou t it. This cer ta in ly seems to be the pract ice in Dubl in and t h roughou t I r e l and genera l ly . I am of opinion t ha t the subject ought to be viewed f rom quite a different s tandpoin t , and tha t once the disease is d iagnost ica ted, this in i tself ought to be quite

~ Read before the Section of Surgery in the Royal AceAemy of Medi- cine in Ireland on Friday, February 23, 1906.

432 A ~oz)e~dicitis.

sufticieilt to have operation carried out. I refer, of course,. to true acute appendicitis, and only to the acute condition, throughout mv communication. I do not say that every" case o~ appendicitis must be operated on to save the patient's life, but I do say that the results of early opera- tive treatment are much better than those at present obtained by what is cal, led expectant treatment. This ~s the opinion heht by the large majority of the best surgeons in America and hv many Continental surgeons of the highest repute.

Instead, therefore, of giving a long list of symptoms that call for operation I would give two or three (.onditi{ms that are opposed to 'it -First, when a patient cannot be operated on under favourable circumstances, and by some one who knows how: second, when the patient is praeti- eally moribund; and third, when some visceral lesion is present, such as bad heart disease, which would ccmtra- indicate any operation whatever.

I can imagine some ten or fifteen years ago men laying down the law when operation should be carried out for intestinal obstruction or for strangulated hernia. I am old enough to have been taught that in the latter con- dition taxis was first to be tried, then a hot bath until the. patient nearly fainted, then taxis again, then an anaes- thetic, and finally taxis while the patient was under the infuence of the anaesthetic. I f the hernia were not then reduced, and the patient happened to be alive~ the ques- tion of operation should be discussed. No wonder the mortality was high, either with or withont operation. Pret ty much the same idea at present prevails with regard to the treatment of appendicitis. When the circum- scribed inflammation becomes diffuse, when the localised abscess bursts into the general peritoneal cavity, when the appendix is sloughing, in short, when the patient is in the worse possible condition for operation, and when the difficulties to the operator are a lmost insurmountable, then, and not till then, are we to attempt to get rid of the offending organ. Consequently, the duration of this most

By MR. DENIS KENNEDY. 433

painful illness is anything from three weeks to as many months, and the mortali ty is said to be from 20 to 25 per cent. Wi th early operation the duration of the illness will be exactly eight days and the mortality nil. Besides, we do not expose our patient to an unnecessary procedure, as we are, I think, all agreed that once a person gets an attack of appendicitis, if not operated on during the attack, and should he survive, he must be operated on afterwards to prevent a recurrence.

There is a widespread notion in the profession, even among operating surgeons, that opening the abdomen during an attack Of appendicitis is particularly dangerous. This I believe to be a complete fallacy. During the last two years I have operated on forty-three cases of acute appen- dicitis. The illness previous to operation varied from eight hours to about three weeks; the pathological conditions found were anything from simple appendicitis to gangrene of the appendix with diffuse peritonitis ; the ages of the patients ranged from three to seventy-one years, and I have not had a single death.

I f operation is carried out before complications have arisen appendicectomy during an attack is just as safe as during the quiescent period; and when complications have arisen, such as peri-appendicular suppuration, opera- tion is no longer a matter of choice, but of necessity.

Most of us are usually able to diagnosticate appendicitis when it occurs. None of us can tell what pathological conditions may be present or ensue during an attack. Diffuse peritonitis, formation of secondary abscess, slough- ing of the appendix, intestinal obstruction, any or all may ensue ~rom what was originally a mild attack, and we may have very little proof of their occurrence till it is too late for our patient.

To show the fut i l i ty of expecting some cases to get welt without operation, and to illustrate the dangers to our patient there may be in delay, with your permission I will give a brief history of some of the cases I have operated on.

CAS~ I.--Master E. F., I saw on Monday, the 17th of December, 2 E

434 Appendicitis.

1905. He was ill from the previous Friday, had persistent vomiting and continuous pain diffuse over the abdomen, but worse over the right iliac fossa. No motion of the bowels had occurred for three days, in spite of large quantities of purgatives that had been administered, and only one ounce of urine had been secreted during the previous twenty-four hours. H i s abdomen generally was distended, and the muscles over the right half were very rigid. Tempera ture was 101 ~ and his pulse-rate 115. I diagnosticated appendicitis with ensuing ileus, and recommended immediate operation. Both the diagnosis and the treatment recommended were agreed to by my colleague Dr. Savage, whom I asked to see the patient in consultation. The boy was sent to a private nursing home, and I operated that evening, Mr. Tobin kindly assisting me. I found the inflamed appendix twisted like the letter U behind the c~ecum, and so firmly fixed by adhesions that the lower end of the c~ecum was bent backwards and up- wards almost at right angles. The ileum was distended. On removing the appendix the cmcum resumed its normal position, and flatus at once began to gurgle through. There was some pus and a good deal of serous and plastic peritonitis in the neighbourhood, especially over the small intestine. I wiped away the pus, provided for drainage, and the boy made a rapid and eomplete recovery.

CASE I I . - -Frances B., aged five years, I was called to see on the 2nd of August, 1905. She was suffering from a typical at tack of appendicitis. Two days subsequently Dr. Savage sa~b the case with me in consultation. The question of operation was discussed, but the child's mother strongly objected. As the disease seemed to be running a normal course, and as there were no urgent symptoms, we consented to wait and adopt the treatment of masterly inactivity. Nothing of consequence happened until the night of the 5th of August, when the child suddenly collapsed, her temperature falling from 102 ~ to 96 ~ . When I saw her in the early hours of Sunday morning her con- dition was one of profound collapse, with its associated symptoms. There was no longer any question of postponing operation if the child was to get the least chance of recovery. Dr. Savage again saw the case in consultation, and agreed as to its urgency. On account of the patient's condition she could not be removed to

By Ma. D s ~ I s KENNEDY. 435

a private hospital, and, consequently, I had preparations made as quickly as possible for operation in her own home. On opening the abdomen by an incision over M'Burney's point I h a d the greatest difficulty in finding the appendix. I prolonged the incision upwards in front of the kidney, as a mass was to be felt in that region. I found a gangrenous appendix lying in a quantity of fzecal pus along the posterior wall of the c~ecum. On removing the debris, which contained some fmcal pellets, the outer coat of the posterior wall of the c~ecum ruptured spontaneously to the extent of about an inch. I at tempted to suture both the appendiceal opening and the rent, but no suture would hold. I greatly feared sloughing of the c~ecum would ensue. I con- tented myself with wiping away the pus and debris as well as possible and packing the parts with gauze. I made a counter opening in the loin, and provided for drainage both through the loin and anteriorly. Nutrient enemata kept the child alive during the next twenty-four hours; then she began to take nourishment by the mouth. No mot ion of the bowels was allowed for the first five days on account of the bad condition Of the cmcum. The child made a perfect recovery, and ha~ not even a Ventral hernia as a sequel.

I am m u c h indebted to the ass i s tance o~ Dr. Savage in b r ing ing this ease to a successful issue bo th dur ing and subsequent to the operat ion.

CASE I I I . - -Miss M., aged twenty-eight years, I sent to Jervis Street Hospital in June, 1904. She suffered from a well-marked attack of appendicitis, and had been ill for twenty-four hours. I kept her under observation for a couple of days, carrying out the usual expectant treatment. She did not improve, and on the evening of the third day of her stay in hospital her tem- perature reached 105 ~ after a pronounced rigor. I operated on the following morning after a consultation with my colleague Dr. Thompson. The appendix was greatly inflamed and dis- tended, and there was well-marked evidence of general serous peritonitis throughout the whole abdomen, without a trace of any adhesion whatever. In a few hours more I have no doubt the abdomen would have been filled with pus. I removed the appendix, flushed out the abdomen with normal sMine solution, and provided for free drainage. The patient made a complete

436 Appendicitis.

recovery. Through my delay in operating, which was due to the prevalent practice, I nearly sacrificed my patient's life.

CASE IV.--Mrs. B., aged seventy-one years, was sent to me to Jervis Street Hospital by my colleague Dr. Savage. Six years previously she had an attack of appendicitis, from which she recovered, but a large swelling remained in the right iliac fossa. I t did not cause her any trouble, and, in consequence, she refused operation. On a Tuesday morning, as she was getting out of bed, she felt something give way in her abdomen ; pain and vomiting quickly ensued. She developed intestinal obstruction with peritonitis, and although urged to operation by Dr. Savage she refused until the following Saturday, five days after her attack began. When I saw her in hospital she was in a semi-comatose condition, and had all the appearance of approaching death. I operated at once, making a long incision over the appendiceal region. The abdomen was filled with pus ; there was no attempt at any limiting adhesion. I quickly re- moved the appendix and provided for free drainage. I neither douched nor in any way attended to the toilet of the peritoneum, for the simple reason that any delay would have caused the patient's death on the operating table. For forty-eight hours the dressings were constantly saturated with pus. Her bowels acted the day after operation, and she made a slow but good recovery, with no sequela, but a fistula from the peritoneal cavity. She left hospital eight weeks after the operation.

CASE V.--A young girl, aged twenty-two years, was admitted to Jervis Street Hospital, April, 1905. Twenty-four hours pre- viously she attended the out-patient department complaining of some abdominal pain ; she refused to be examined, and, con- sequently, was not prescribed for. She returned to her home; pain continued during the day and night, associated with vomiting. The following morning she collapsed, and was brought to hospital in the city ambulance. I saw her in consultation with my col- league Mr. Byrne. We diagnosticated perforating appendicitis, and carried out immediate operation. The whole r e , o n around the appendix and the pelvis were filled with pus, without any limiting adhesions. The appendix was intensely inflamed, and perforation had occurred through the c~ecum, half an inch from the base of the appendix. I sutured the perforation, removed

By MR. DENIS KENNEDY. 437

the appendix, wiped out the pus and debris with gauze sponges wet with hot saline solution, and provided for free drainage. No douching was employed. She made a good recover-.

CASE VI.--Mr. S., aged fifty-six years, I saw in consultation with Drs. Savage and O'Carroll in August, 1905. Patient was six days suffering from appendicitis, and a large swelling wae present in the right half of the lower part of the abdomen. He had been a liberal drinker, suffered from fat ty degeneration of the heart, with congestion of the lungs, liver and kidneys. Albumen was present in the urine in quantity. We were unani- mous as to the gravity of the case, but the difficulty was to find a solution. The condition of his abdomen demanded operation, his general condition was totally opposed to it. On the advice of Dr. O'Carroll we decided to wait for twenty-four hours in the hope of improvement supervening. That night the patient had rigors, and next day his condition was decidedly worse. Con- sequently, I carried out operation, being assisted by Mr. Tobin and by Mr. Keegan, who gave the anmsthetic. I opened the abdomen by incision over the appendiceal region, and evacuated a large abscess from between the coils of small intestine and behind the eeecum. The suppuration was limited by marked adhesions. I could have removed the appendix only with great difficulty and a prolonged operation. I contented myself, there- fore, with wiping out the pus and providing for free drainage. The patient made a good but protracted recovery under the care of his physician, Dr. Savage, in spite of the fact that three weeks after his operation he got an at tack of profuse h~emo- ptysis, which was probably due to h~emorrhagic infarction of his lung. He can be seen again at all the Irish race meetings prosecuting his calling as a bookmaker with great vigor.

CASE VII.--Mr. M., aged thirty years. I was brought to Camden Street about 3 30 a.m. on the morning of the 23rd of November, 1905, to see this patient, who had gone to bed qlfite well on the previous night, but woke about midnight with violent pain in his abdomen, which was followed bv vomiting, When I saw him he was collapsed, his legs were drawn up ; there were great tenderness and rigidity of the muscles over the right side of the abdomen, especially over the iliac region. His temperature was 10~ pulse-rate 115, I diagnosticated fulminating appendicit

438 Appendicitis.

and sent him at once to Jervis Street Hospital in the ambulance. I operated a few hours subsequently. On opening the abdomen pus was everywhere present without a trace of any limiting adhesion. I found the appendix enormously distended, with a perforation about half an inch from its tip. Through this per- foration pus was flowing freely into the abdominal and pelvic cavities. I removed the appendix, wiped out the pus, which

was present in quantity, and provided for free drainage. I used no douche. The patient made a rapid and complete recovery. His case is especially interesting from the ~act that six months

Appendix, with constriction towards the csecal end and a small perforation near the tip, removed from Case VII.

previously he had an attack of enteric fever, which so resembled appendicitis that a positive diagnosis could only be made with the Widal reaction. He also suffered from well-marked mitral regurgitations.

W i t h regard to the diagnosis of the disease, it does not as a rule present any great difficulty, especial ly in adults. Murphy , of Chicago, lays special stress on the order o4 the oc<'urrence of the symptoms. He s a y s - - " There is first abdominal pain, sudden and severe, fol lowed by nausea and vomit ing, general abdominal sensitiveness, elevation of tempera ture , beginning f rom two to twenty-~our hours a f te r tile onset of the pain. These symptoms occur, almost

By Ma. DENIs KENNEDY. 439

without exception, in the above order, and when that order varies I always question the diagnosis." He also says " tha t temperature in acute appendicitis must always be present, and that it never precedes pain." I think this summing up of the symptoms is as near as we can get to a good guide to the early diagnosis or the normal illness in adults. Two symptoms that are often relied on for a dia- gnosis are very fallacious. First, ~he right leg I have never seen drawn up, even when an abscess was present: Both legs may be drawn up when diffuse peritonitis exists. Second, the most tender spot is not always M'Burney's point, lJut varies according to the position of the tip of the appendix.

The rectum, and in females ~he vagina, should always be examined to determine whether pelvic suppuration is present or not, and no examination of a child is satisfac- tory without an anaesthetic. In children the diagnosis sometimes presents great difficulty, as is illustrated by ~he following case : - -

C~SE VIII.--Baby K., aged three years, suffered for five days from violent spasms of abdominal pain; there was no vomiting, no elevation of temperature, and only slight constipa- tion. During the intervals of the attacks of pain the child seemed well. On careful examination I found a thickening over the region of the appendix, and there was considerable tenderness present. The spasms of pain passed off gradually, the child's general condition improved, but the swelling and tenderness in the right iliae fossa seemed to get more pronounced. Consequently I recommended operation, which I carried out in the Private Hospital, 20 Mountjoy Square, assisted by Dr. Savage and Mr. Keegan. On incising over the appendiceal region I found a large mass adhering to the anterior abdominal wMl. To get into the abdomen I prolonged my incision upwards, and was then able to separate the mass from the anterior parietes. I found the mass to consist of a very long, thick appendix, with the distal half enveloped by the lower part of the omentum. I amputated the appendix, excised the part of

t

omentum involved, and removed the whole mass tobether. Pro- lessor McWeeney examined the specimen, and reported that it. showed undoubted signs of having been the seat of repeated

440 Appendicitis.

attacks of inflammation; while the part of the appendix and omentum matted together were on the point of breaking down into an abscess. The child made a rapid and complete recovery

The incision I make for appendicectomy in acute cases is the one that crosses M'Burney's point. I avoid the muscle-splitting operation, as I believe its advantages are outweighed by its disadvantages. I f the appendix is in an abnormal position it is difficult or impossible to find

Appendix, enveloped by omentum, removed from child, Baby K., aged three years.

it with such an incision, and if the incision has to be enlarged the operation presents many difficulties. Our aim in operating ought to be twofold--first, remove the offending organ if possible; secondly, where peri-appen- dicu]ar suppuration exists, free drainage should be pro- vided for. In some cases it is not possible to remove the appendix, however desirable it may be, without endanger- ing the patient's life, especially when abscess exists. The manipulations necessary to free the appendix may cause serious injury to an inflamed bowel in the neighbourhood, or may carry infection to a wider area than was previously

By Mm DENIS KENNEDY. 441

involved ; or the condit ion of the pat ient may be such as to forbid a prolonged operation. For tunate ly , its removal is not always necessary to save the patient 's l i fe ; but convalescence will be more prolonged, suppuration will be more persistent, and, consequently, there will be much more risk of a ventral hernia ensuing. Besides, a focus of infect ion is lef t in the abdomen which may give rise to trouble again in ei ther the near or remote future. W h a t , however, is absolutely essential is, t ha t where pus is pre- sent, whether localised to the neighbourhood of the appendix or not, free drainage must be provided for. I th ink on this largely depends the success of the operation as a l i fe-saving means. I employ for drainage a slit rubber tube with a gauze wick. I change the gauze as soon as it becomes saturated, as I believe once tha t occurs it acts as a plug, not as a drain.

We must remember tha t pus m a y be present in quant i ty from appendicitis e i ther in the pelvis or in the retro- cmcal region, and no sign of i t appear when we open the abdomen. Consequently, if we have to search for a sus- pected abscess these are the two most l ikely regions in which we will find it. Fur ther , if pus exists free around the appendix it will most l ikely have made its way to the pelvis. The question of drainage th rough the vagina or rectum must then be considered. I have met with retro- c~ecal appendicit is and suppurat ion in four cases. The ~.ondition may be suspected if, in connection with appen- dicitis, there are a fulness and tenderness in front of the renal region. In one of my cases in a child, a lready men- tioned, the appendix was completely gangrenous, and lay well up in f ront of the kidney.

The points to be remembered in operat ing in these cases are, first, we must prolong our incision upwards, and, secondly, to reach the trouble we must draw the caecum and ascending colon towards the middle line. We can thus remove the appendix, get r id of the pus, and establish free drainage th rough the loin or anter ior ly without the ]east danger of the general peritoneal cavity becoming infected.

442 Appendicitis.

I am no believer in the extensive procedures that are sometimes carried out in cases where suppuration exists in connection with appendicitis. These consist in remov- ing the appendix at any cost, in free manipulation of the intestine, in excising every portion of the omentum that comes near the pus, in breaking down adhesions freely, and in douching, swabbing, and paying elaborate atten- tion to the toilet of the peritoneum. I am thoroughly con- vinced that whether suppuration is localised or diffuse, the peritoneum is well able to look after itself, if it gets a fair chance, by free exit being given to the pent-up inflammatory exudation, and that, when diffuse suppura- t ive peritonitis exists, the quicker the operation is finished and the less manipulation there is of the intestine the better chance there is for the patient.

Douching, if used at all, should be employed only when the fluid used can escape by a counter-opening as freely as it enters the abdomen and when a large part of the abdominal cavity is in~ected. Under these conditions it is certainly harmless unless for the time it takes, bu t its benefit is a very doubtful quantity. Rough sponging injures the delicate endothelial lining of the peritoneum, and thereby tends to destroy its inherent power of resist- ing infection. I content myself with gently wiping away any pus that I find with a gauze sponge wet with normal saline solution. I have practically given up the use of the douche altogether in these cases. Manipulation of the intestine to any extent I look upon as being decidedly dangerous.

In conclusion I may s a y - (l) The dangers of operating in an acute attack of

appendicitis have been greatly exaggerated, and with proper care are most imaginary.

(2) When suppuration is diagnosticated, operation should not be delayed in the hope of adhesions being formed and the pus becoming circumscribed.

(3) Children who get the disease usually have to be operated on for recovery.

By ~Ia. DENIS KENNEDY. 443

(4) Our motto in t rea t ing the disease should b e - - " Leave no th ing to chance." Consequently, have the appendix remove({ as ear ly as possible.

I owe an apology to the members of this Section Sot b r ing ing such a well-discussed subje~.t before them and for my inabi l i ty to t reat it in a communicat ion such as this in a ny th ing like an exhaus t ive manner .

THE .~E.TIOLOGY OF LEPROSY.

DR. E. S. GOODHUE, Government Physician, writes as follows, under (late April 9, 1906, from The Doctorage, Government Road, Laaloa, Holualoa, Hawaii, T. It. : - -" You will be glad to hear that Dr. W. J. Goodhue, Medical Superintendent of the Leper Settlement at Molokai, after several years investigation there, has been able to demonstrate the Bacillus lepr~e of Hansen in the mosquito and in the bed-bug. I will quote from Dr. Good- hue's official (but as yet private) report to the Hawaiian Board of Health.--Feb. 10.--' We have since been sectioning mosquitoes taken from various leper houses, but until last June without any apparent success. At that time it appeared that we had isolated bacilli in these series of experiments, but owing to the technique employed it was impossible to confirm this. This method of research was then abandoned. After repeated failures and constant re-examination of fresh specimens, success has come as far as demonstrating the Bacillus lepr,'e in the female mosquito (Culex pungens). Feb. 20.--I have since writing you last discovered the bacillus in the common bed- bug (Cimex lectularia). I believe that the Cimex is more of a factor in the spread of leprosy amonq the natives than the gnat ' (here follow reasons). Full reports of the work with microphoto~aphs of slides will be given publicity in May."

LITERARY NOTE.

MR. HFtNEMANN, 20 and 21 Bedford Street, Londo:l, W.C., h-ts in preparation a useful little work for the general practitioner and the medical student, on " The Management of the Commoner Infections," by Dr. R. W. Marsden, Hon. Physician to the Ancoats Hospital, and Hon. Assistant Physician to the Hospital for Consumption, Manchester.