Clinical Lecture ON THE ADVISABILITY AND THE METHOD OF OPERATING IN CASES OF ACUTE INFLAMMATION OF THE APPENDIX IN THE PERIOD FROM THE THIRD TO THE SIXTH DAY
SENIOR SURGEON TO THE LONDON HOSPITAL. GENTLEMEN,-I have taken up this question to-day for two reasons. The first is that in my opinion it is the most important question in the treatment of acute inflammation of the appendix that still remains unsettled. Everyone who has seen a large number of cases agrees now that the sooner an appendix which may be on the verge of giving way or of becoming gangrenous is removed the better it is for the patient. Everyone, too, agrees that, in the later stages
... n the later stages of the disease, when the acute attack is subsiding and the condition of the patient improving iu every respect it is advisable and safe to wait. But everyone does not agree as to what should be done in the intermediate stage of an acute attack, when the patient is seen by the surgeon for the first time between the third and the sixth day after the onset of the acute symptoms, at a time when the septic inflammation has already spread widely into the general peritoneal cavity, and there is no indication whether it is going to stop or to spread more and more widely. These are the cases that furnish the highest rate of mortality after operation, a rate so high that some have advocated not operating upon them at all, and this is one reason why I wish to deal with them to-day. My other reason is that we have had of late an unprecedented series of acute cases, even for the London Hospital, and that a large proportion of them have reached this stage before they applied for admission. Of course, the stage of which I am speaking is not marked off by any definite symptoms from that which precedes or that which follows it. In an attack which is fairly acute it extends, roughly speaking, from the end of the second day to the sixth or seventh, but it is influenced by many things. In children, for instance, it begins much earlier than it does in adults. It may begin in them within the first few hours. Then it is influenced, perhaps more than you would think, by the anatomical position of the appendix, whether, for example, it lies behind and to the outer side of the cascum and colon, or hangs free in the peritoneal cavity ; and, of course, it is influenced by the intensity of the inflammation and the virulence of the organisms that are causing it. Exact definition, therefore, is out of the question, but, roughly speaking, the third to the sixth day may be looked upon as its limits. A very large proportion of the acute cases that come to the hospital are seen by the surgeon for the first time after they have already entered upon this stage, and I am sorry to say not a few of those which occur in private. No matter what the actual number of hours may be, the clinical symptoms are usually so definite that there is no difficulty in recognising this stage when it is reached. The attitude and the aspect are characteristic. The patient lies upon the back with the knees drawn up. The eyes are ringed with black circles. The cheeks are sunken. The lips are dry and the tongue, unless there has been recent vomiting, is dry and already brown. The respiration is entirely costal. The whole abdomen is distended, hard, rigid, and motionless. The muscles are too tense and the walls too sensitive for you to be able to distinguish anything by pressure; but on light percussion the note is distinctly flatter in the right iliac region than it is elsewhere. The pulse is quick and rapid, usually over 100 to the minute. Exceptionally, in two or three instances, I have found it quite slow and fairly soft. The temperature is raised two or three degrees. Rectal examination, which should never be neglected, reveals a certain degree of fulness and tenderness, especially upon the right side. In many instances the rectal temperature is one or even two degrees higher than it is in, the mouth, so high that the difference can be appreciated even without a thermometer. Such, gentlemen, leaving out all detail, is in brief the description of the condition of the patient. It means, of course, as is patent to you all, septic peritonitis spreading from the right iliac fossa and becoming generalised. The appendix, the source of all the trouble, is either gangrenous, or has given way, allowing the liquid contents of the bowel, with perhaps a fascal concretion, to escape into the surrounding tissue. The actual position which it occupies, and the route along which the inflammation is extending, are not known, but occasionally there is an indication of some value. An exceptionally tender spot, for instance, in the lumbar region, just over the crest of the ilium, means that the cellular tissue behind the colon is involved, and that the inflammation is tracking upwards along the posterior abdominal wall. If there is great tenderness on rectal examination, especially if it is high up, or more marked upon the right side than the left ; or if there is pain on emptying the bladder with, at the same time, increased frequency of micturition, it is probable that the appendix is lying on, or over, the brim of the pelvis. If, as in many of these cases, the attack is very acute and sudden, and the whole abdomen becomes involved almost at the same time, probably the appendix is lying on the inner side of the caecum and has ruptured into the general peritoneal cavity ; and this is rendered more likely if the left side of the abdomen rapidly becomes as tender and painful as the right. But at the best all of these are only probabilities. If there is an operation they indicate to some extent where and how drainage is to be carried out. They help but little in determining whether an operation should be performed or not, and that is the point to which I wish to direct your attention to-day.