A Report of Six Months' Work in the Out-Patient Department for Diseases of Women at the Boston City Hospital
Boston Medical and Surgical Journal
from the severity of tho attack, or because other reasons make an operation in a remission desirable. It would therefore seem wise in such cases as threaten the necessity of operation to operate early. My conclusions then would be : (1) The operation with its attendant difficulties and possible danger should be presented first, to those in whom a condition of invalidism is produced by the frequency or severity of the attacks ; second, to those who are prevented from performing their ordinary
... g their ordinary duties in life ; third, to those whose surroundings are likely to be such that they cannot in time of urgent necessity, command the services of an experienced surgeon (this would apply to those whose home was where good surgical skill was not available and those who travel by land or sea, and are likely to be seized with an attack at a distance from home). (2) That the surgeon should be sufficiently familiar with abdominal surgery to be able to meet the difficulties which ho may encounter. (8) That in such cases as threatened the necessity of operation, it is better to do it in a remission, when those preparations of the patient, instruments and dressings can be made which are requisite to an aseptic operation. OPERATION. An incision should bo made along the outer border of the rectus, curved or straight, about three inches long, in such a manner that the centre of the incision shall be over the usual site of the appendix. This can be made larger later if complications arise which demand it. This can be made with a free hand until the peritoneum is reached. This can be recognized by the praa peritoneal fat. All bleeding points Bhould be tied or controlled by haunostatic forceps, and the wound made dry before the peritoneum is opened. This should bo done the full extent of the wound. The appendix should be sought, and if not seen the linger introduced into the wound. The touch will often determine the location of the appendix, which is usually thickened or feels rounded and tense from the retained secretions. METHOD OF REMOVAL. The appendix should, when found, be separated from its attachments from its mesentery by tying it in sections and division with the scissors, and from surrounding adhesions by gentle pressure with the finger or sponge. Any bleeding is best controlled by pressure with sponges or gauze. Ligature may occasionally be needed. The appendix should be ligatcd with silk near to the c;ucum aud removed, great care being used that none of its contents escape into the wound. TREATMENT OF THE PEDICLE. I have found in my cases that it was impossible to invert the edges and suture the serous surfaces, and have treated the lumen of the appendix like the cervix uteri iu an hysterectomy by the actual cautery, and then stitched a (lap of omentum over its top, the stitches being placed in the shape of a horseshoe with the open part towards the centre of circulation in order not to impede it. In this way the pedicle is quickly shut away from the general abdominal cavity by thé adhesion of the omental flap. In some cases it has been possible to invert the ed^es of the pedicle and suture them. That is a good method where practicable. I believe that the cautery is safer than dusting the cut surface and lumen with iodoform, boracic acid or aristol, and of the three I should prefer the last. THE TREATMENT OF THE WOUND. The cavity of the wound should be thoroughly cleansed and in suitable cases should be closed throughout. Tho peritoneal surfaces should be approximated independently by a continuous or interrupted silk suture, then the rest of the wound by silk sutures. In one case I closed by three sets of sutures: the first closed the peritoneum ; the second, the muscular and aponeurotic structures ; and the last, the skin, by a buried suture. The wound healed throughout by immediate union, and up to the present time thero has been no tendency to hernial protrusion. In cases where pus or tho contents of the appendix have escaped into the wound after thorough cleansing, it should be packed with iodoform gauze, and iu some cases a drainage-tube is required. The ¡inmediato closure of the whole wound averts as far as possible the danger of ventral hernia. A l-TElt-TREATMENT. Immediately after operation a subcutaneous injection of an eighth of a grain of morphine to be repeated p. r. il, a rectal injection of four ounces of black coffee to be repeated iu two hours, if there is any shock. Absolute diet for two days. Nutritious enemata during this time, then liquid diet for about a week, if the case is progressing favorably. Dressings should not be disturbed for ten days, unless indicated by the temperature. Stitches removed in fourteen days. The patient then allowed to sit up in bed, and to be about in four weeks, unless there is some special contra-indication.