Essay upon the Classification of the Various Forms of Appendicitis and Peri- typhlitic Abscess, with Practical Conclusions. BY AEPAD G. GEESTEE, M. D., SURGEON TO THE GERMAN AND MOUNT SINAI HOSPITALS ; PROFESSOR OF SUUGBgYAT Tl'K york'polyclinic. REPRINTED FBOM STju Neto York fSetrical journal for July 5, 1890. Reprinted from the New York Medical Journal for July 5, 1890. ESSAY UPON THE CLASSIFICATION OF THE VARIOUS FORMS OF APPENDICITIS AND PERITYPHLITIC ABSCESS, WITH PRACTICAL CONCLUSIONS* By ARPAD G. GERSTER, M. D., SURGEON TO THE GERMAN AND MOUNT SINAI HOSPITALS ; PROFESSOR OF SURGERY AT THE NEW YORK POLYCLINIC. Up to within a recent period of time it was the preva- lent belief that perityphlitic suppuration was located retro- peritoneally, and most generally in the iliac fossa, whence it found its way to the surface by pushing aside the perito- neal reflection corresponding to Poupart's ligament. Wil- lard Parker's method of incising perityphlitic abscess was based upon this view. It can not be denied that the development of most cir- cumappendicular abscesses seems to confirm this view, and that the rules laid down by Parker for the treatment of this group of suppurative processes have yielded, and continue to yield, very satisfactory results in very many instances. Still, it must be said that the exceptions to Parker's type are considerable in number. Formerly they were classed as cases of general or localized " idiopathic peritonitis." * Read before the New York Surgical Society, May 14, 1890. 2 APPENDICITIS AND PERITYPHLITIC ABSCESS. Their treatment was non-surgical, and their issue very un- certain and often fatal. We owe the better understanding of the elements of this phenomenon to Treves and Weir, but principally to McBur- ney, who demonstrated that in the vast majority of instances the formation of abscess in the right iliac fossa was due to in- traperitoneal inflammatory processes, mostly of the vermi- form appendix, and commonly accompanied by ulceration, necrosis, and perforation of this viscus. The frequency of the location of perityphlitic abscess near the parietes of the right iliac fossa is explained by the frequency of the super- ficial situs of the appendix in this region. In these cases the type of development so well described by Parker will prevail. But in a very large proportion of instances the vermiform appendix, either congenitally or in consequence of acquired peculiarity, occupies a deep situation, and in these cases an appendicular perforative process is sure to cause a deep-seated intraperitoneal abscess, more or less distant from the surface, hence infinitely more grave and dangerous both as regards its deleterious possibilities and the difficulty of diagnosis and surgical management. As soon as it became clear that widely different intraperitoneal forms of suppuration might be caused by extension from the appendix, and that their manner of development was wholly unforeseen and unaccountable, a violent oscillation in therapy was initiated by those who proposed, in all cases where the appendix was suspected of causing trouble, a bold exploration by abdominal section, and the extirpation of the appendix, or evacuation at all hazards of the purulent col- lection, wherever it might be found, and all this without delay. Though this bold course of therapy has, in spite of its experimental character, yielded very good results in the hands of various surgeons, and although its adoption was APPENDICITIS AND PERITYPHLITIC ABSCESS. 3 absolutely necessary for establishing a clearer understand- ing of the nature of the morbid process in question, never- theless it must be remembered that a vast proportion of perityphlitic abscesses do not need operative invasion of the free peritoneal cavity for their successful cure, and that a sweeping advice to the general profession to open the peri- tonaeum in every case where appendicular trouble is sus- pected is, for obvious reasons, fraught with much unwar- rantable danger. Formerly it was considered purely accidental whether an intraperitoneal abscess would appear here or there, and the variability of the surroundings and location of these ab- scesses was deemed so irregular and erratic that, to the au- thor's knowledge, no attempt was ever made to study the question whether a certain order of development did not prevail even in those forms of perityphlitic abscess which could not be classed with the well-known inguinal type de- scribed by Parker. If some light could be thrown upon the detailed nature of these seemingly erratic forms of circum- appendicular abscess, instead of the crude general advice to "perform laparotomy," more precise, hence safer, methods of treatment would suggest themselves. Let us first emphasize the fact that all intraperitoneal abscesses are of visceral origin, and that perityphlitic ab- scess in particular is due to inflammatory processes located in the vermiform appendix. Though not always, this form of abscess is mostly established within the peritoneal sac. The proof of this assertion has been so manifold that it is only necessary to refer to the numerous cases of early appen- dicitis reported by McBurney and other observers, in which, on laparotomy, the free appendix was found to be tightly dis- tended by a copious exudate, and more or less erect by dint of its extreme distention; its walls thickened, hypersemic, occa- sionally exhibiting unmistakable signs of circumscribed necrosis 4 APPENDICITIS AND PERITYPHLITIC ABSCESS. with perforation imminent. This distension was uniformly- produced by occlusion toward the gut. Occasionally decay had progressed to actual perforation and the formation of incipient abscess, surrounded by a protective barrier of recent adhesions of the vicinal serous surfaces. The appendix was invariably found to be the starting point of the trouble, and the affection, with rare exceptions, always intraperitoneal. Aside from the numerous instances in which the intraperitoneal and appendicu- lar character of perityphlitis was established by positive observa- tion, the following case may serve to show that the retroperito- neal space back of the iliac fossa is not the seat of abscess in typical cases of perityphlitis. In the spring of 1887 Dr. Lell- mann, then on duty in the German Hospital, requested the au- thor to operate on a case of perityphlitis pertaining to his service. The operation was delayed twenty-four hours on account of a misunderstanding, and the next day-a dense, painful tumor being found in the right iliac region-incision according to Par- ker was done, in spite of the circumstance that the size of the swelling had somewhat diminished since the previous day. The peritoneal lining of the iliac fossa was easily stripped up two inches beyond the external iliac vessels, so that the tumor was freely raised with it from the underlying tissues. No sign of inflammation was found, and, as the case was mending, it was not deemed prudent to incise the peritonaeum. The very deep wound was drained and closed, but no pus appeared. Simul- taneously with the healing of the incision the tumor disap- peared, and the man was discharged cured within a fortnight after the operation. We need not do more than hint at the causes of appen- dicular inflammation. Let us first mention the impaction of foreign bodies entering from the gut, acute or chronic forms of catarrhal or ulcerative (typhoid) enteritis, transmitted from the colon and leading to simple hypertrophy or to ulceration, both of these causing irregular constriction mostly in the vicinity of the attachment of the appendix. Another not infrequent cause of stenosis is the doubling upon itself APPENDICITIS AND PER1TYPIILITIC ABSCESS. 5 and fixation of the appendix in this position. Stenosis by flexion is thus produced (F. W. Murray, N. K. Med. Jour., May 24, 1890, p. 564). With the establishment of hyper- trophy and stenosis a loss of contractile power is associated, leading to more or less complete retention and to the in- spissation of faecal matter, which finally assumes the shape of one or more globular concrements. As long as the com- munication with the colon is fairly open, no local symptoms need prevail. As soon as the stenosis becomes considerable, the well-known signs of appendicitis make their appearance. If they are due to a passing state of catarrhal hypersemia, their acuteness will vary in proportion with the intensity of the stenosis. Thus, with the cessation of causal intumes- cence and' the elimination of the stenosis maintained by it, all trouble may seemingly or really disappear. A case reported by Shrady * aptly illustrates this train of symp- toms : A physician had had four distinct attacks of appendicitis, in all of which the question of operation arose. Dr. Shrady had seen the patient at New York in three of the attacks, all of which were well pronounced, while the fourth occurred in Paris, where the patient was seen by a distinguished surgeon, who made a like diagnosis. There also the question of an op- eration came up. Each attack was attended with all the usual severe symptoms which would appear to usher in the formation of an abscess; there was dullness, tenderness, more or less ri- gidity, and some oedema in the neighborhood of the caecum. In each attack the advisability of operation was freely discussed. The patient was willing to take the risks, but in each instance the symptoms gradually disappeared, and he recovered. He asked Dr. Shrady, should he survive him, to examine his appen- dix, which was done when death occurred, some time subse- * George F. Shrady, Meeting of Practitioners' Society of N. Y. Med. Record, April 26, 1890, p. 479. 6 APPENDICITIS AND PERITYPHLITIC ABSCESS. quently, of another cause. The appendix was found perfectly sound. There was not the slightest appearance of any inflam- mation around it; it was not even thickened. Where ulcerative processes have led to the formation of a permanent cicatricial contraction, the appendical trouble is apt to persist even after the cessation of the causal dis- order of the intestine. Passing states of local intumescence are then more likely to lead to complete occlusion of the communication between gut and appendix, with serious consequences. But even in these cases temporary improve- ments are possible with the diminution of the acute swell- ing of the cicatricial mass. Before attempting apractical classification of the phases of appendicitis and of the localities in which circumap- pendicular suppuration is to be observed, this fact has to be pointed out: that, unfortunately, the acuteness or mildness of the local or general symptoms is not an invariable index of the ultimate gravity of a given case. Sometimes fatal cases will set in with a very deceptive mildness of appear- ances. On the other hand, a very alarming beginning may be followed by resolution or a tractable state of affairs. Hence it must be insisted on that, in reference to this trouble, all therapeutic advice has only a conditional value -to be weighed and accepted or rejected by the surgeon in each separate case. A. Acute Appendicitis (without Tumor). (a) Simple Appendicitis (No Tumor).-Anatomy teaches that in the supine body the attachment of the vermiform appendix can be found directly underneath a point located two inches from the anterior superior spine of the ilium, on a line connecting this bony prominence with the navel. Whenever acute and persistent pain appears in this region, APPENDICITIS AND PERITYPHLITIC ABSCESS. 7 accompanied by fever and retching, the pain being marked- ly increased by palpation of this area, trouble of the appen- dix can be confidently diagnosticated. In women, biman- ual palpation ought to exclude the presence of an inflam- matory process of the displaced uterine appendages. Though the local and general symptoms may be very alarming, tumor can rarely, if ever, be detected in the early stages of the affection. Meteorism is also absent. In view of the impossibility of foretelling whether, in a given case, spontaneous evacuation of the contents of the appendix or perforation is to take place, and in the latter case whether a superficial or a deep-seated abscess is to develop; and, considering the fact that laparotomy fol- lowed by excision of the appendix has yielded uniformly good results if done before the access of perforation, it is safe to follow McBurney's advice, which recommends laparotomy and removal of the appendix whenever severe symptoms persist and increase for more than forty-eight hours. The steps of the operation are these: A longitudinal incision, four or five inches long, parallel with and just outside of the outer margin of the right rectus muscle. Hav- ing opened the peritonaeum, the appendix is found, which will be rendered easy by first ascertaining the location of the caput coli. The mesentery of the appendix is included in a double ligature of stout catgut and divided. Then the root of the appendix is secured by two ligatures, be- tween which the viscus is cut off. The mucous lining of the stump is either seared with the thermo-cautery, or, after careful disinfection, is touched with a few drops of perchlo- ride-of-iron solution and dried off. Then the stump is dropped back and the external wound is closed. Case.-Miss F. L., aged twenty, has had altogether sixteen or eighteen attacks of appendicitis within two years. Oharac- 8 APPENDICITIS AND PERITYPHLITIC ABSCESS. teristic local pain, irregular fever with temperatures reaching 104° F., no tumor. Uterine appendages normal. April 20, 1890.-Laparotomy. The free appendix is found very much thickened, its distal half distended and bent upon itself, containing a quantity of foetid serum. It was removed. Uninterrupted recovery. (6) Perforative Appendicitis (No Tumor').-Sudden in- crement and extension of the local pain followed by symp- toms of collapse, such as profuse cold sweating, a thready pulse, anxious expression, pallor, frequent vomiting, and the appearance of meteorism are indications that perforation and infection of the peritonaeum have taken place. This rarely occurs before two or three days after the inception of the trouble. The violence of the symptoms will depend on these factors. If the extent of the perforation is small, and only a small quantity of the infectious contents of the appendix has made its way into the peritonaeum, a limit- ing barrier of protective adhesions may be thrown about the infected area within an hour or so. In this case the alarming features of the case will somewhat subside and a tumor is apt to develop. If, on the other hand, the per- foration is large or multiple, a considerable volume of in- fectious material will suddenly escape. Lively peristaltic action will widely distribute it, and more or less extensive local or, in the worst cases, general septic peritonitis will be established. The absence of tumor in conjunction with very acute local and general symptoms represents an extremely grave combination of things, its meaning being a generalizing peritonitis. In these cases the prognosis is very doubtful, and it will be extremely difficult to save the patient, even by the most resolute measures. If laparotomy is imme- diately done, the focus laid open, wiped out clean, the ap- pendix removed, and the cavity packed and drained, some APPENDICITIS AND PERITYPHLITIC ABSCESS. 9 chances may still be present for the patient's recovery. But where, on account of delay, numerous and widely dis- seminated abscesses have established themselves in the more remote parts of the peritoneal cavity, the patient's death is nearly certain. Prolonged exposure, the impossibility of a sufficient evacuation and drainage of the foci which are found, finally the overlooking of distant foci located in the loins, in front and behind the liver, will sufficiently explain this fact. Case I.-William Sachse, aged forty-eight, liquor-dealer, was treated since September, 1889, in the internal department of the German Hospital for alcoholic neuritis. No habitual constipa- tion. March 83, 1890.-Sudden chill. Temperature, 105°. Slight amygdalitis. No abdominal symptoms. The temperature re- mained high, although the patient's bowels were well purged with calomel on March 25th. Had a chill in the preceding night, another one in the afternoon, complaining the first time of bellyache. 27th.-Pain well marked in ileo-caacal region. Was trans- ferred to surgical service. Temperature, lOPd:0 F. Meteorism, intense pain in ileo-ceecal region, but no tumor and no dullness. Vomited only once. Laparotomy at 3 p. m. McBurney's in- cision. Peritoneeum filled with turbid serum. Omentum widely adherent to caecum, in front of which an adherent and very much thickened and elongated vermiform appendix was found. On freeing this, a large, irregular abscess cavity was opened, which did not anywhere approach the parietes, and which was situated below and behind the caecum, its walls being formed everywhere by intestines. At the root of the appendix a large perforation was seen, with three globular fecal concre- ments lying in front of and outside of it. The appendix con- tained three more globular concrements of the size of a small marble. The appendix was isolated, tied, and cut off. Another large abscess situated in the median line, and a third one in Douglas's pouch, were opened, irrigated, and drained. Hasty partial closure of incision after packing and drainage of the ab- 10 APPENDICITIS AND PERITYPHLITIC ABSCESS. scesses on account of collapse. In the night the temperature rose to 106° F., and the patient expired toward midnight. Post- mortem examination revealed three more abscesses, one situated high up behind the liver. Case II.-David Danziger, tailor, aged twenty-two. Gen- eral peritonitis due to perforative appendical trouble of six days' duration. Laparotomy January 29, 1889, at Mt. Sinai Hospital. Seven abscesses were opened and drained. Patient seemingly improved, the quality of the pulse improving. Vomiting ceased, but he collapsed suddenly thirty hours after the operation and died. Post-mortem examination revealed three .perihepatic abscesses. B. Acute Appendicitis with Tumor ; Perityphlitic Abscess. Whenever perforation of the free appendix occurs, the invasion of the peritonaeum is regularly signalized by the usual symptoms of perforative peritonitis. As before men- tioned, a circumvallation by adhesions will form in those cases in which only a small quantity of infectious material has escaped. This seems to be the usual course of events. Occasionally, however, the inflamed parts of the appendix will first become adherent, and then be perforated. In these cases the alarming intermezzo possessing the typical aspect of perforative peritonitis will be missed, and the abscess witl develop without a tendency to meteorism and collapse, and with a gradual but steady growth of the mainly local symptoms. The complex of symptoms has little of the character pertaining to peritonitis, and resembles that of an ordinary abscess. By contiguous extension, which is mostly slow, these abscesses may assume very large proportions. Neglected for a long time, especially if they are limited by intestines only, their secondary rupture, followed by a chill and further extension, or even their generalization, may occur. This, however, is not common in the early stages of the process. APPENDICITIS AND PERITYPHLITIC ABSCESS. 11 The only case of this kind observed by the author occurred nineteen days after the inception of the trouble. Case.-H. D., clerk, aged twenty, subject to alvine slug- gishness, contracted, after a more than usually severe spell of constipation, a deep-seated, hard, painful, perityphlitic swelling. Cathartics failed to relieve the bowels, and, high fever with vomiting having set in, the author was consulted. May 7, 1878.-Typical swelling of a cylindrical shape was made out in the right groin, and a number of repeated large in- jections of tepid water into the gut were employed without success. 3d.-The peritoneal symptoms, notably vomiting, became very distressing, wherefore this therapy was abandoned and opium treatment begun. At the same time an ice-bag was placed over the swelling. The change effected a decided im- provement in the subjective symptoms, but the swelling con- tinued to increase and the fever remained unrelieved. 17th.-Spontaneous evacuation of a large, formed stool oc- curred. 19th.-The general condition becoming very poor, incision was urged, but was firmly declined by patient and parents. Suddenly, in the night of the same day, perforative symptoms developed. The patient died, May 20th, of septic peritonitis. Post-mortem examination demonstrated an internal perforation of the abscess, and putrid septic peritonitis. Had the patient consented to the operation, the case might have turned out dif- ferently. Perforation took place on the nineteenth day after the invasion. The presence of a tumor, which always indicates the ex- istence of protective adhesions, implies a certain amount of temporary security and, under certain circumstances, may justify a short delay of the operation. Types of Acute Perityphlitic Abscess. Although the classification of perityphlitic abscess ac- cording to location can not be made with geometrical pre- 12 APPENDICITIS AND PERI1YPHLITIC ABSCESS. cision, yet it will be found that most cases can be naturally massed in a series of roughly defined groups. The small number of intermediate or transitory forms does not vitiate the practical value of this grouping, upon the right under- standing of which must be based some important variations of the operative technique. It is the author's wish to firmly maintain the importance of the principle that every intraperitoneal abscess should, if possible, be opened and drained without invading the normal peritoneal cavity-that is, through existing planes of adhesion to the parietes. With few exceptions, all peri- typhlitic abscesses have such an approachable side. To study, to ascertain, and to utilize them is the duty of the conscientious surgeon. It is idle to state that safely incis- ing and draining an abscess through a laparotomy wound- that is, through the free peritoneal cavity-is an easy or indifferent matter. No competent person will believe it. 1. Ilioinguinal Type (Willard Parker's abscess).-The normal situation of the caput coli and appendix vermiformis near the parietes of the right iliac fossa has the consequence that the great majority of circumappendicular suppurative processes will naturally establish themselves so as to have for one of their limiting walls the parietal peritonaeum of that region. This has led to the erroneous belief that peri- typhlitic abscess is normally located behind the peritoneal lining of the iliac fossa. This situation involves the great practical advantage that the abscess can be permitted to assume certain propor- tions so as to render its incision simple and free from the danger of invading the normal peritoneal cavity. There- fore, when an immovable tumor develops in the right iliac fossa soon after the inception of the malady, it is safe to wait a few days until the abscess has assumed a certain size. On the fourth, fifth, or sixth day it may be safely incised. APPENDICITIS AND PERITYPHL1TIC ABSCESS. 13 Searching for pus with a hollow needle is superfluous when the abscess is superficial-that is, immediately beneath the parietes; dangerous if it is deep-seated, as the gut might be thus injured or the healthy peritonaeum infected. Case.-Francisca Bertrand, aged forty-five, was taken ill with fever early in July, 1882, and developed a deep-seated, painful swelling in the left iliac fossa, with high fever and peri- tonitic symptoms. On the afternoon of August 5th probatory puncture brought out some pus, wherefore, with the aid of the family physician, Dr. Assenheimer, incision was practiced by Hilton's method. A large quantity of pus escaped, and a drain- age-tube and ancL-eptic dressing were applied. In the follow- ing night very acute peritonitis set in, to which the patient suc- cumbed August 6th. No doubt the reflection of the perito- naeum was injured, and part of the pus must have entered the peritoneal cavity. The only safe way of opening these abscesses is by methodical and careful dissection, layer by layer being divided by an ample incision placed through the longer axis of the tumor. The vicinity of pus will become manifest by the discoloration and condensation of the tissues. When the abscess is opened and the bulk of its contents has es- caped, a gentle exploration by the index-finger is advisable to detect recesses or a foreign body. But all rough treat- ment of the walls of the cavity by scraping, tearing, or rude squeezing is reprehensible, as it may lead to inward rupture. For the same reason search for and removal of the ulcer- ated or necrosed appendix from the abscess is to be avoided as unnecessary and dangerous. Two drainage-tubes are slipped into the cavity and fastened in the usual manner. They will facilitate irrigation without causing undue dis- tention. A daily change of dressings will be required for the first week or ten days. As soon as the discharge be- comes scanty and serous, the tube should be removed. 14 APPENDICITIS AND PERITYPHLITIC ABSCESS. The ilio-inguinal type is undoubtedly and fortunately the most common form of perityphlitic abscess, and its time- honored therapy as laid down by Parker will have to be retained as safe and successful. In sixteen cases of the ilio-inguinal group operated on by the author according to Parker's plan, only one terminated fatally, by erysipelas. The patient was under treatment for hip-joint disease when, unfortunately, the complication with perityphlitic abscess set in. Case.-Ernestine S., servant-girl, aged nineteen, admitted March 2, 1880, to the German Hospital, with the diagnosis of hip-joint disease, the symptoms of which were indubitably pres- ent. Emaciating fever, and the characteristic flexion and ad- duction of the thigh, together with swelling of the gluteal and infrapubic regions, seemed to admit of no doubt. Examination under ether, however, revealed a fluctuating swelling of the right groin, which yielded pus on puncture, and was incised. A large quantity of pus and the stem of an apple or pear were evacuated. Another incision below Poupart's ligament estab- lished drainage of an abscess communicating with the peri- typhlitic gathering. The lower extremity was put into Buck's extension, and the cavities were daily irrigated. Operative measures, directed against the profuse discharge from the lower incision-that is, drainage or exsection of the hip joint-were contemplated, when the girl contracted erysipelas, and died of it in May, 1880. Post-mortem examination established the fact of hip-joint suppuration, a communication of the perityphlitic abscess with the joint being found, by way of the iliac bursa. 2. Anterior Parietal Type.-Next in frequency to the ilio-inguinal form of perityphlitic abscess is the type ac- cording to which the bulk of the purulent collection is found immediately behind the anterior abdominal parietes of the right side. Frequently this is associated with a more or less apparent ilio-inguinal tumor, and might be looked upon as its extension. The swelling is generally found be- APPENDICITIS AND PEPvITYPIILITIC ABSCESS. 15 hind the right rectus muscle, its shape vertically elongated, its upper limit occasionally extending beyond the level of the navel to the hypochondrium, its proximal margin to or beyond the median line. When an unmistakable continua- tion of the tumor can be traced into the right iliac fossa, the abscess can be safely opened above Poupart's ligament, as in the preceding group. But occasionally the upper ex- tension will require a separate incision. Case I.-Abraham Jacobson, tailor, aged twenty-two. Peri- typhlitic abscess of six days' duration, the iliac tumor extending inward and upward to the inner margin of the rectus muscle, the space above Poupart's ligament feeling empty. November 19, 1888.-Typical incision at Mount Sinai Hos- pital, a little below and to the inward of the anterior superior spine; drainage. Retention of pus in the upper pocket, hence, November 26th, second direct incision. Rapid improvement. January 17 th.-Discharged cured. Case IL-David Frank, butcher, aged forty-two. Perity- phlitic abscess of eight days' duration ; tumor extended upward along the line of the rectus muscle to within a hand's breadth of the costal margin. December 8, 1889.-Incision two inches and a half to the in- ward of the anterior superior spine. Evacuation of about a quart of pus; depth of abscess, twelve inches; though the wound was doing well, surgical delirium set in, and the patient was transferred to his home December 24th, where, as his family attendant reported, he soon recovered entirely. When it is found that the iliac fossa is normal and en- tirely void of resistance, and a circumscribed tumor can clearly be felt some distance from the ilium and Poupart's ligament, it is necessary to ascertain where to make a safe incision. If the extent of the tumor is great, a direct in- cision might be confidently made. But if the superficial extremity of the tumor is small, it will be safer to first open the peritoneal cavity in the median line by a small incision, 16 APPENDICITIS AND PERITYPHLITIC ABSCESS. and digitally explore the exact relations and extent of the adhesion. Having thus located the abscess, the exploratory cut is closed, and the abscess is incised by a direct route. Case I.-Miss Evelyne II., school-teacher, aged twenty-three. Perityphlitic abscess of two weeks' duration. Small tumor to the right of median line, underneath right rectus muscle. Iliac fossa empty. Per vaginam, tumor was felt adherent to anterior abdominal wall, and with it bimannally movable backward and forward. March 7, 1890.-Exploratory laparotomy in median line be- low the navel. Just to the right of incision, partly solid, partly fluctuating mass could be felt, its walls being evidently formed of intestine, among which the empty appendix was seen firmly attached. By passing the finger around the attachment of the tumor to the anterior abdominal wall, it was found that the iliac fossa contained healthy intestine, and that the tumor was in no wise connected with it. Fixation of tumor by fingers in ab- domen ; puncture through abdominal wall; foetid pus. Closure of laparotomy wound by suture. It was sealed with a strip of rubber tissue moistened with a little chloroform. Incision of abscess along the line of puncture ; evacuation of five ounces of pus. Uninterrupted recovery. Discharged cured, April 10, 1890. Case II.-Mark Beermann, hat-maker, aged nineteen. Peri- typhlitic abscess of seven days' standing. Somewhat movable tumor underneath right rectus muscle on a level with umbilicus. Iliac fossa normal. November 30, 1889.-At Mount Sinai Hospital, median ex- ploratory laparotomy. Location of adhesion, which was very limited, was established by digital exploration. Closure of laparotomy wound. Incision and drainage of abscess. Dis- charged cured January 11, 1890. Perityphlitic abscess of the anterior type may extend to and beyond the median line, when it will hold close relations with and may perforate into the bladder. Case.-Henry Marks, aged seventeen, suffered from habitual constipation and frequent attacks of colic. In June, July, and APPENDICITIS AND PERITYPHLITIC ABSCESS. 17 August, 1878, severe attacks of colic were noted and overcome by the use of purgatives. August 25th.-Dr. L. Weiss, the family attendant, made out typhlitis and ordered a laxative, which, however, failed to re- lieve the patient. Thereupon opium was methodically exhibited until September 6th, when the patient had a spontaneous and copious, formed evacuation. September 7 th.-The temperature rose to 104° F.; the ex- ternal swelling in the right groin became very marked. 10th.-The author saw the patient in consultation with Dr. Weiss. A uniform puffy swelling was found occupying the right groin, and was extending beyond the median line of the abdo- men. Frequent urination distressed the patient a good deal, who exhibited the usual hectic symptoms of long-continued sup- puration. Deep fluctuation was made out, and evacuation of the abscess was determined upon. The transversalis fascia being gradually exposed, it was found infiltrated and firmly attached to the underlying tissues. A probatory puncture made in the bottom of the wound, close to the os ilium, gave pus, where- upon the abscess was freely incised, and a large quantity of matter was voided. No foreign body could be found. Digital exploration demonstrated a long sinuosity extending toward the median line to a pocket occupying the prevesical space. A drainage-tube was placed into the main abscess, another one was carried into the prevesical space, and the wound was dressed with carbolized gauze. The patient's wretched condi- tion at once commenced to improve; appetite and sleep re- turned, and the profuse night-sweats disappeared. 20th.-The drainage-tubes became disarranged, and were found slipped out of the wound. Difficulty was experienced in replacing them, and symptoms of retention, with renewed pain and fever, set in again. 23d.-The author again saw the patient, and replaced the tubes. A considerable quantity of pus was found in the pre- vesical pocket. From this date on uninterrupted improvement was noted, and the patient got up October 10th. October 20th, the tubes were withdrawn, and October 30th the fistula was closed. 18 APPENDICITIS AND PERITYPHLITIC ABSCESS. In this case imminent perforation of the bladder wall was prevented by timely incision. 3. Posterior Parietal Type.-Whenever perforative pro- cesses occur in an appendix located near the posterior parietes of the peritoneal cavity-for instance, near the right sacro-iliac synchondrosis or the lumbar region-the result- ing abscess will naturally have a deep situation. Cases will occur in which incision of such an abscess can not be made unless it be done through a laparotomy wound. But there can be no doubt that in a certain proportion of these cases a safe incision may be made from behind. Case I.-James Solomon, schoolboy, aged thirteen, April 18, 1889. Perityphlitis of five days'standing. In consultation with Dr. W. Morse, an indistinct, very deep-seated, and painful tumor was felt in the region of the sacro-iliac juncture of the right side. By April 22d the tumor had considerably enlarged, and seemed to lie just beneath the right rectus muscle. At Mount Sinai Hospital laparotomy was done the same day over the site of the swelling, which was found to hold no connection whatever with the anterior abdominal wall, but was firmly ad- herent to the posterior wall of the pelvis. The ascending colon formed the outei' wall of the tumor. The appendix could no- where be found, and was undoubtedly imbedded in the mass of the tumor. The anterior wound was closed, and a long hollow needle was thrust into the region of the tumor from behind, entering the pelvis a little to the inward of the line of the pos- terior superior spine, its direction being downward and forward. Pus was gained at great depth, and the abscess was incised and drained from there by a rather long and deep incision. All the febrile symptoms disappeared, and the boy was discharged cured June 3, 1889. Case II.-Samuel Gross, tailor, thirty-three years old, was laparotomized at Mount Sinai Hospital, January 27, 1889, for internal obstruction of six days' standing. Faecal vomiting was present, with enormous tympanites due to intestinal paralysis. The cause of the obstruction was found in a very long and much APPENDICITIS AND PERITYPHLITIC ABSCESS. 19 distended appendix vermiformis, the apex of which was firmly attached to the under surface of the right half of the transverse mesocolon. Through the loop thus formed about three feet of the ileum had slipped and had become strangulated. Corre- sponding to the attachment of the apex of the appendix a mass- ive swelling was felt occupying the space behind the colon, and when the adhesion was severed, pus welled up from a small aperture corresponding to the site of the attachment. This led into an abscess cavity which was carefully evacuated. The ap- pendix being removed, the intestines were replaced with con- siderable difficulty. The patient died an hour and a half after the operation. (For complete history, see N. Y. Med. Journal, May 4, 1889, page 478.) Case III.-Mr. M. G-., aged sixty-two, had been suffering from habitual and very obstinate constipation for years. In May, 1880, profuse diarrhoea set in, and could not be controlled by any of the usual dietetic and therapeutic measures. A grave deterioration of the general condition developed, and the patient lost very much flesh in spite of forced feeding. August 31st.-Fever set in, and the presence of a painful swelling in the iliac fossa was made out. September 3d.-The author saw the case in consultation with Dr. W. Balser and Dr. L. Conrad. A large fluctuating swelling occupied the right half of the pelvis, and tympanitic percussion sound was noted in the lumbar region. Two incisions were made-one above Poupart's ligament, another in the lumbar region-and an enormous amount of gas, pus, and faecal matter was evacuated. Profuse secretion and diarrhoea continued, and the patient died September 22d. Post-mortem examination revealed a tight cancerous strict- ure of the ileo-caecal valve, and an enormous dilatation of the lower portion of the ileum, which resembled thick gut. Large masses of impacted faecal matter were found in this pouch, which was adherent to the posterior parietal peritonaeum, and was freely communicating through a number of ulcerous defects with the abscess cavity. 4. Rectal Type.-It is a good rule never to neglect to examine the rectum of a patient suffering from perforative 20 APPENDICITIS AND PERITYPHLITIC ABSCESS. appendicitis. A long appendix may become fixed and per- forated in the small pelvis, and an abscess is then apt to develop in close vicinity to the rectum, whence it can be safely opened and evacuated. The objection that faeces might enter the abscess has thus far not been verified by experience. Case.-August Petry, clerk, aged eighteen, was admitted, November 10, 1887, to the German Hospital with symptoms of perforative peritonitis. General tympanites prevailed, and a tumor could not be felt anywhere, but intense pain was com- plained of on pressure in the right iliac fossa. The poor state of the patient forbade operative interference, and opiates and stimulants were exhibited. By November 13th the patient had fairly rallied. An examination of the rectum disclosed the pres- ence of a fluctuating swelling corresponding to its anterior wall. An incision evacuated a large mass of pus, and a drainage-tube was placed into the cavity and brought out through the anus. The tube was not borne well. It excited tenesmus, and was re- peatedly expelled. As the patient was doing very much better, and the tumor had disappeared, it was left off without ill con- sequences. The patient was discharged cured November 27, 1887. 5. Mesocodiac Type.-To characterize that most serious form of circumappendicular abscess, the walls of which are composed entirely of agglutinated intestines, and which hold no immediate relation whatever with the parietes of the abdominal cavity, the term " mesocadiac " was chosen (from al KOihiai, the intestines, and ev peoG), between). The abscess is found occupying, as it were, the middle of the peritoneal sac. Hence, to reach and evacuate this form of abscess, the free peritoneal cavity must be opened, and the collection of pus must be reached by separating the adherent coils of gut which inclose it. We owe the development of the technique of the evacua- tion of these abscesses mainly to McBurney, whose pro- APPENDICITIS AND PERITYPHLITIC ABSCESS. 21 cedure is as follows: A longitudinal incision, as for simple appendicitis, is made parallel to and along the outer border of the right rectus muscle. The abnormal cohesion and re- sistance of the implicated intestines will point out the site of the abscess. The protruding normal coils of gut should be packed away under a protective bulwark of sponges held in situ by the assistants' hands, so that, if the abscess is opened unawares, no pus should soil the healthy perito- naeum. Two of the nearest coils are now gently and cau- tiously separated by gradual traction, exercised by the oper- ator's fingers, until a small quantity of pus is seen exuding. It is desirable to let the pus escape slowly, so as to have ample time to sponge it away as it pours out; otherwise the whole field might be overwhelmed and contaminated by a sudden flood of matter. Note.-It seems that exhausting the abscess through a small aper- ture by means of a syringe would be an improvement upon the mop- ping up by sponges. As soon as the bulk of pus has been removed, the cavity is wiped out clean with sponges dipped in an antiseptic solution, and now the adherent intestines are still more separated to permit the surgeon to inspect its interior. If the appendix is loose and easily to be got at, it can be removed, but, if it is found closely adherent and very brit- tle, it is better to remove only so much of it as will come away easily. A good-sized drainage-tube is placed into the bottom of the cavity, which is, in addition, loosely filled with strips of iodoform gauze. These and the rubber tube are brought out near the lower angle of the wound, and the abdominal incision is closed in the usual manner. If the case is progressing well, the packing can be withdrawn on the third day, as by that time protective adhesions will have formed between the adjoining coils of gut. The 22 APPENDICITIS AND PERITYPHLITIC ABSCESS. drainage-tube is to be removed as soon as the secretions become serous and scanty. C. Chronic or Relapsing Appendicitis and Perityphlitic Abscess. It was shown how simple catarrhal conditions of the raucous lining of the appendix may lead to more or less complete occlusion of the exit of this viscus. The reten- tion of the secretions will then cause distension and the train of symptoms characteristic of appendicitis. With the diminution of the catarrhal swelling of the mucous mem- brane, a restitution ad integrum will take place. Usually the symptoms produced by this form are mild and tracta- ble. Bland laxatives and opiates, rest in bed, with some form of local applications, generally bring about a lasting recovery. Where ulcerative processes, prolonged inflammation, or the doubling of the appendix upon itself, have caused the formation of cicatricial matter-hence permanent steno- sis of greater or lesser intensity-the recurrence of severe obstructive symptoms will be more frequent, the intervals between the attacks shorter and shorter, and the tendency to the formation of adhesions more pronounced. Thus the very chronicity of the process will yield, in its tendency to the formation of adhesions, a certain protective character. Should perforation occur, these adhesions fulfill a most im- portant function in preventing general septic peritonitis. The number of relapses of appendicitis may be very great; in one of the author's cases sixteen were counted. With the increase of the cicatricial stenosis, the formation of concre- tions, and the loss of contractile power of the appendix, the tendency to ulcerative or gangrenous lesions becomes more and more pronounced, and finally culminates in per- foration. APPENDICITIS AND PERITYPHLITIC ABSCESS. 23 As we have no means of ascertaining- the exact condition of the appendix, frequent recurrence and increasing severity of the disorder clearly justify an attempt at its removal. The term "attempt" is used here purposely to signify that such endeavors may occasionally be baffled by intricate and close adhesions, which a prudent surgeon may prefer not to disturb for fear of lacerating the gut. It may be said, however, that, should the first attempt fail, a second one may be crowned with success.* All surgeons admit the, occurrence of the spontaneous evacuation of perityphlitic abscesses into an adjoining part of the gut. Occasionally perforations into the bladder, rectum, or even the pleura, have been observed and de- scribed. If such an evacuation into the gut is followed by a perfect obliteration of the cavity and fistula, no relapse will occur. Should evacuation be imperfect, inspissation of the retained pus and a temporary dormancy of the acute signs of the process will result, until some local irritation again provokes rapid intumescence, followed by evacuation of the surplus contents of the abscess. This process may be repeated a number of times, as a result of which a thick mass of cicatricial matter will be deposited around the focus. Cases of this order demand surgical interference. Case.-Miss Caroline D., aged fourteen, had had within two years three attacks of perityphilitis with well-marked ilio- inguinal tumor, which never disappeared completely. On April 24, 1888, Dr. L. Arcularius presented her to the author, who advised an operation. A small immovable tumor could be felt occupying the iliac fossa. On May 1, 1888, an incision was made, and a small cavity of the size of a chestnut was laid open. * I take the liberty of referring to a verbal communication of Dr. F. Lange, who informed me that he once had to abstain from removing the appendix through an anterior incision. Later on the organ was successfully removed through a posterior wound. 24 APPENDICITIS AND PERITYPULITIC ABSCESS. Its walls consisted of a massive deposit of cicatricial matter, its contents of a putty-like mass of inspissated pus, surrounded by a coating of deciduous granulations. When all the soft matter was scooped out, a narrow sinus was traced to a depth of an inch and a half beyond the bottom of the cavity. The wound was packed, and was kept open with considerable difficulty during the entire summer, small quantities of feculent matter escaping from time to time. In the course of the following winter the tumor gradually shrank away, the discharge dried up, and, the tube being removed, permanent healing took place. Had the outer opening been permitted to heal, recur- rence of the abscess would have probably followed, as clos- ure of the communication with the gut came about with a great deal of hesitancy. The same state of affairs may and does often prevail in abscesses that are evacuated by the surgeon, and in which the outer opening shows a more pronounced tendency to closure than the sinus leading from the abscess cavity to the gut. Thus the presence of a how- ever minute faecal fistula that has not healed soundly may bring about a number of recurrences in the tract of the old abscess. It stands to reason to say that inadequacy, both as regards the quality and duration of drainage of the abscess cavity, has a most important influence upon the retardation of the closure of the faecal sinus. Hence the tendency to relapses will be very pronounced in cases where evacuation of the primary abscess took place spon- taneously. Case.-Frank Kennedy, printer, aged twenty-five, had suf- fered since childhood from a number of attacks of smart pain in the right groin accompanied by fever. In the early part of 1885 he acquired an oblique inguinal hernia of the right side, and was ordered to wear a truss, the pressure of which, if the pad became displaced outward, caused intense suffering, so that he had to abandon its use from time to time. In June, APPENDICITIS AND PEBITYPHLITIC ABSCESS. 25 1885, during a severe attack of fever, an abscess broke open two inches and a half below the anterior superior spine. Since then healing and reopening of the sinus had occurred four times. On March 3, 1886, a dense deep-seated tumor could be felt in the right groin, independent of the hernia, which could be easily replaced. Following the existing sinus, the center of the indurated mass was laid open by a large incision running parallel with Poupart's ligament. At the depth of two inches a globular smooth-walled cavity was exposed, within which, imbedded in frail granulations, a stratified coprolithon of the size of an unshelled almond was found. A channel of the di- ameter of a goose-quill was seen leading from this cavity in- ward and downward, into which could be slipped twelve inches of a slender drainage-tube. When water was thrown in through this tube, diluted faecal matter regurgitated. Under the micro- scope this matter was seen containing granules of amylum and fat with fat crystals arranged in the shape of sheaves. The wound was kept packed with gauze till March 25th, and was healed, seemingly from the bottom, by April 14th. On Novem- ber 15,1886, the fistula reopened, and the proposition was made to the patient to expose the site of the faacal sinus from within by laparotomy, and to deal with it by extirpation of the appen- dix or enterorrhaphy. He declined to take the risk, and pre- ferred to wear a tube permanently. Sparse quantities of a fecu- lent, orange-colored serum continued to escape from time to time until the end of 1888, when the tube could not be replaced once, and was abandoned. As it seems, permanent healing then took place. The proposition made to this patient to close his faecal fistula by laparotomy and an appropriate dealing with the involved gut, contains the essence of a plan the adoption of which might be necessary in order to bring about the speedy cure of an apparently interminable, most disagree- able, and loathsome ailment. But the necessity for the adoption of such extreme measures must be very rare in- deed. On the whole, it may be said that the recurrence of an 26 APPENDICITIS AND PERITYPHLITIC ABSCESS. evacuated perityplilitic abscess is comparatively rare, and that, if it is due to the presence of a faecal fistula, its lasting cure can in most instances be effected by prolonged and ef- ficient drainage of the outer wound. Another cause of prolonged suppuration within and around an incised pcrityphlitic abscess is the formation of one or more extraperitoneal burrows and cavities, located between the several layers of the abdominal wall, which are the direct consequence of inadequate measures at drainage. The primary cause of the abscess may be eliminated, the perforative aperture of the appendix or gut may long since have permanently closed, and yet frequent relapses of sup- puration will keep the patient confined to the bed. How to deal with a case of this kind may be seen from the fol- lowing history : Mrs. E. T., aged thirty-two, was operated for perity phlitic abscess by a prominent gynaecologist of this city in the latter part of the summer of 1887. Four weeks after the operation the drainage-tube was withdrawn, and the wound healed prompt- ly, but a reaccumulation and evacuation of pus soon followed, and symptoms of recurrent retention were observed on an aver- age every four or six weeks until January 13,1889, when, by the same practitioner, bloody dilatation was done with the confident expectation of lasting success. These hopes, however, remained unfulfilled. Up to March 1, 1889, three more recrudescences occurred which were closely observed by the author. Each time symptoms of retention were present, though a large and long drainage-tube was constantly in situ, reaching to the bottom of the wound. Circumscribed swellings occurred then once above, another time to the inner side of the sinus, and pus was seen welling up on pressure from the drainage-tube. It was decided to find and remove the cause of this distressing condition by an operation, which was done March 11, 1890, in the presence of Dr. Lange and Dr. Bull, of this city. The tract within which had lain the drainage-tube was exposed to its bottom by an incis- •on nine inches long, and running parallel withPoupart's ligament. APPENDICITIS AND PERITYPHLITIC ABSCESS. 27 Carefully examined, it was found to be soundly and firmly closed at the bottom, no manner of communication existing with the gut, though it was evident that only a thin layer of tissue separated the cavity from the peritoneal sac. On the lateral aspect of the smooth lining of the old drainage track, and not far from the bottom, two minute apertures were seen inosculat- ing, into which the probe passed for a distance of two and four inches, respectively, the longer track leading toward the navel, the shorter upward toward the crest of the ilium. When these narrow tracts were slit up, each of them was found terminating in a small pocket containing granulations and pus. These sinuses were located within the abdominal parietes, between the mus- cular and peritoneal layers. Unavoidably, the peritoneal cavity was opened in two places, but, as no tumor could be felt within, these apertures were not enlarged. The very large wound was purposely left open, and the dressing consisted in an iodoform- gauze packing. Uninterrupted healing followed, though it took a long time on account of the size of the wound. June 3d.-The patient was discharged cured, and has re- mained well ever since then. Conclusions.-1. Mild, presumably catarrhal, forms of appendicitis require no operative measures, but dietetic and medicinal treatment by opiates, laxatives, rest, and local ap- plications. 2. The more severe and persistent forms of appendicitis may render excision of the appendix advisable, especially if frequent recurrence, with increase of the violence of the symptoms, is observed. 3. Most perityphlitic abscesses hold close relations with one or another of the abdominal parietes. The location of the parietal adhesions of the abscess is to be first ascer- tained, if necessary, by exploratory laparotomy, and the abscess is to be then incised and drained through the area of adhesion, thus avoiding infection of the sound perito- meum. 4. Perityphlitic abscesses that possess no parietal adhe- 28 APPENDICITIS AND PERITYPHLITIC ABSCESS. sions and have a mesocceliac situation between free coils of intestine must be reached by laparotomy through the unin- volved peritoneal cavity. Precautions have to be taken not to infect the normal peritonaeum. 5. Recurrence of suppuration in the groin, following spontaneous or artificial evacuation of a perityphlitic ab- scess, may be due either to the persistence of a small faecal fistula, or to the presence of secondary intraparietal sinuses caused by inadequate drainage and retention. In the first case prolonged and efficient drainage is to be employed for a long time before resorting to artificial closure of the faecal fistula by laparotomy and enterorrhaphy or otherwise. In the second case all sinuses and pockets have to be found by free and careful dissection, and, when they have been slit up and scraped, the wound is to be treated by the open method to effect a sound cure. REASONS WHY ff''S&'WA Physicians should Subscribe - FOR - The NewYork Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. I. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. 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