A FEW REMARKS ON APPENDICITIS.

By CECIL STEVENS, m.d. (Lond.)i f.r.c.s., MAJOR, I.jr.S.,

Professor of Anatomy and Surgeon to the Medical College Hospital, Calcutta.

Though it may be doubtful whether cases of

appendicitis are really increasing in frequency, I think there is little doubt, that they are brought to our notice more often now than before, and consequently that the disease has assumed a

great public importance during the last decade. The apparent increase is probably due to more accurate diagnosis. Appendicitis has, unfortu- nately, become almost a household word, and there are few families who have escaped altogether.

Causation.

<

A suggestion has been recently made that the disease is infective, and due to a special, as yet undiscovered organism. As the morbid pro- cesses of appendicitis are the same as those which occur in other parts of the body, and as the appendix itself is geographically placed in such a way, as to make the natural cleaning of its

cavity very difficult, I think that we must wait for a very full demonstration of special infectivity before we believe in it. On the other hand, there are, no doubt, families in which cases of appendi- citis have occurred one after the other in a

decidedly suggestive fashion. As regards the effects of ingested substances, foreign bodies have been often found, but they must be regarded as accidental, while foecal concretions themselves ecome septic foreign bodies, and no doubt preci-

pitate attacks of appendicitis. I have removed an appendix containing a hard foocal concretion neaily as big as the last Joint of my little hnger.

Heie, in Bengal, cases of appendicitis occur

among> all classes of the population. So that 1 would be difficult to lay the blame on any special class of food. Statistics such as are avail-

able would be useless and fallacious, as amongst the Indian cases, probably only a very small

proportion are ever discovered. The effects of chronic constipation as a factor in the causation of this disease are well known, and its connection with certain cases of chronic colitis is, I think, fairly established. Tubercular cases seem rare

out here. I have not come across any tuber- cular appendices, but have met some very chronic abscesses, which I have suspected to be tubercu- lar in character. As a cause of a recurrent attack of appendi-

citis injury or trauma must not be forgotten. In one case under my charge, a fall from a bicycle against a tree trunk brought on a well-defined attack. In another case, the attack was ascribed to a blow in the groin from the corner of a

table whilst a still more instructive example followed in a few hours the first coitus after con-

finement, the patient having suffered in the seventh month of pregnancy from a severe attack of

appendicitis.

Onset and Symptoms.

The characteristic position of appendicular pains and tumours is almost as well known to the

lay public as to medical men, so much so, that it

may be necessary to insist oil the fact that appen- dicitis may be present, at any rate, in the earlier stages when the pain complained of is far distant from the usual appendicular region. In a very bad case when the appendix had been perforated and was afterwards found running inward and

lying crossways, hanging over the brim of the

pelvis, the pain complained of was epigastric and in the left hypogastric region. It was only after the lapse of some hours, that the tenderness was more clearly defined on the right side, and subse- quently remained there. In another case, a lady, who had come by train, arrived in great abdo- minal pain, with fever, sickness and diarrhoea. She was not treated by me at this period, but she t old me that the pain was a very severe colic, such as she had never previously suffered, whilst her vomiting started very soon. She was, not

unnaturally, treated for indigestion, and after a few days was better, but the pain did not leave her entirely. After the lapse of a week, she took a meal of curry and rice, with the result that she immediately had a relapse with fever and acute pain. On examination I found no pain over the csecum but a very decided tenderness

H inches below the umbilicus, and an inch to the

right of this joint. She had a foul breath and coated tongue. I diagnosed appendicitis in an

appendix which was lying transversely towards the promontory. The tenderness persisted in this region, and nowhere else. The acute colic pain ceased, but the foul tongue and fever persisted. A blood couut showed a moderate leucocytosis- Widal's test was negative. She was treated medically, and after three weeks her temperature fell, the pain disappeared and her tongue became clean simultaneously. I have no doubt myself

,iin(,1y examined for mo by Captain tjmslie omitn, the Chemical Examiner to Government. It.

Carbonates and Phosphates of Calcium and

detected a gaVe leact'on of bile. No chloresterine was

Oct., 1910.] APPENDICITIS WITH ABSCESS, m

that this was a case of appendicitis in an appen- dix situated in a highly dangerous position. As all who have experience in abdominal

surgery can say, the position of the pain as

pointed out by the patient may be a very poor guide to the locality of the trouble. In a

case which afterwards turned out to be a volvulus of a floating caecum, the pain was most acute in

the epigastric region, whilst in another case

recently operated on by the writer, the pain chiefly complained of, was also epigastric, and " round the heart." On opening the abdomen the

ruptured sac of an extra-uterine pregnancy was

found, the abdomen being hugely distended with blood, which fact, no doubt, accounted for the

precordial pain. Fain at the umbilicus is very common in many forms

of abdominal trouble. In the later stages of appendicitis, as will be

shown afterwards, appendicular abscesses may be found at a considerable distance from the diseased

organ.

Course With or Without Abscess Formation.

If the appendix remains imperforated and has not collected pus in its lumen, the cure or rather

temporary cure may be complete in a few days, and the patient may be well enough to resume his or her ordinary work in a few days after the

symptoms have entirely subsided. This is a

course often followed, but not to be advised, as though symptoms may be slight, the ex-

tent of the injury must remain unknown. Other cases approaching perforation no doubt become

protected and buttressed by adhesions to omentum and gut before any actual perforation takes place. It is, in all probability, in these cases that trouble subsequently arises by trauma, the protective cover- ing being torn off, and the appendicular contents allowed to escape. In the case already alluded to as occurring after coitus, the appendix half an inch from the end was perforated and adherent by the thinnest of membranes to the parietal peri- toneum. This in all probability was partly torn

across, and leaked during her last acute attack with the result that in a few hours she had a rigor, her pulse rose to 125, and her temperature to 103, and she suffered the most acute agony. I had

everything in readiness fur immediate operation, but was guided by a falling pulse and tem-

perature to stay my hand, for the time being. I he appendix was subsequently removed by an

"interval " operation and the patient is now quite ^ell- Those cases in which gut and omentum nave come to the rescue of an appendix before

perforation usually speedily resolve and generally give no trouble, but the writer believes that

spilling of the contents of an inflamed appendix ^niongst the surrounding structures generally leads f? an actual abscess. Such abscesses need not be

arge and may be undiscoverable by the ordinary lrieans of diagnosis. In one case a lady presented p'mptoms of subacute appendicitis, a little low

eve>', slight tenderness over the appendicular

region a little tension of the musclesover it ? decided tumour, and only slight fpr. J '

i

rectal examination. Althouo-h sj)e w e#rness by no.thickened appendix could' be felt' 1?'

6 sPai*??

necessary warning to her to remain iifbed it entire rest, and so slight were bp.- i

which, when I saw her, she had already had""f8' ten days that I did not see her again for 'a few ?lays. She then told me that she was ,?,,l better but had had an attack of dysentery On asking her symptoms she said that at first she hi,I passed mucus and then ??ICUS and y

?

Now these are the ordinary symptom^CTn abscess is about to burst into the Ih-o-p k i ,

I think that if the pus had been' located?' "the appendix, I would have been able to feel it Ihere were no more bowel troubles. Abscesses following appendicitis may be looked for ovel ,

very large area; in the writer's own Pvnn?: 7i have occurred in the right hypochondri^11001 ?

'

? ill i ? ? i i. i "-"onuiiac region right lumbar region, right hypogastric region left hypogastric region. One was f?mid nea,.f gj,;?" the pelvis and compressing the rectunji j ?>

, ?

strange case the pus made its way down h spermatic cord. Hie case at first was taken by ? e to be that of a suppurating eord, until farther examination showed that I was rp-ilNr a ,

a pericecal abscess. Besides the abscess S r "h cellulitis especially tracking Up by the side of the colon, is not uncommon. I? ll)is 00n

.

e

may confess to have been much p?zz|ed in '

, cases which came under my hands. I? tbese c 1 masses of stony hardness were found inat u

'

fi the costal border on the right si^tt^ close to the iliac crest, or between these two regions. They were so hard and definite that hv

they were diagnosed as sarcomata On rr flipm PVffilir. - v/u

some

opening them except quite su^St muscular structure of the abdominal w 11

to the naked eye to have disappeared, and h?n'w of it was dense inflammatory fihrmic +;

1

the hardest type. Amongst' the Xr,e T ?f was usually a little pus, or granulation I now believe these cases to be r ,

"ue-

origin, as since then I have seen the of appendicular abscesses, "radnnll .

? ?.n'c the abdominal wall as described. Tn^fV lnvading there has probably been a cellulitis

1<?Se Cases

ing an appendicular abscess, which has^n-T^T the gut in the more usual way whiUf ?

0

the septic contents has become' shut"off ̂ ?'^on duced the chronic abscess above descrb f* are not in the writer's experience ensv

6 -^ei'e

The damaged, fibrosed abdominal wmW^68 *reak

a very long time to soften, c0 fl',. f ta^e

extremely slow. I have not nief H lea',n& ,s

abscesses elsewhere. I hope at <?mn 'cur[0as to produce more definite proofs nf n

" e ^me

dicular origin. It must be remembered tint1""'" appendicitis may cause serious * ,

an

adhesions which have been left bphiJ\??iS a rule, it is marvellous how abdominal ndhesW

402 THE INDIAN MEDICAL GAZETTE. [Oct, 1910.

clear up after the lapse of time. In one ease, in which the writer saw in consultation with Dr. McCombie, and Colonel G. F. Harris, i.m.s., the patient found that gas collected in his coecal region producing a localised distention of the size ot a small hand. He feared that he had a new

growth, blocking his bowel. However, as he had previously had attiicks of acute colic pain which might well have been due to appendicitis, we agreed upon an exploration of the appendix. Ihis was found twisted and contorted, and bound down by adhesions, whilst two separate bands ran across the caecum and divided it into two chambers, in which no doubt the gas used to collect. I removed the bands and the appendix, and the patient made an excellent recovery. No growth was found.

Treatment.?My former teacher, Mr. C. B. Lockwood in his most valuable work on appen- dicitis, which should be in the hands of all who are likely to meet with these cases, lays stress on the individual nature of each instance of the disease. There was never a truer observation. Every case differs and each must be considered and treated on its merits. There are no golden rules by which the treatment may be simplified. It is, I believe, agreed now that if all cases are left to medical treatment 80 per cent, may be expected to recover from that attack, whilst it is also probably truly claimed, that with very eai 1} operation the percenta ge of successes may be extended to nearly cent, per cent. This is competing in theory. If we could 1 ive in an

appendicular utopia in which patients at the earliest sign of appendicitis came smilingly to the right surgeons, who stood ever ready to remove the peccant appendage ; all would, no doubt, be

nnu ^^fortunately we have to deal with facts. The^ man in the street may be pardoned for hoping sometimes that his case is to be one of the 80 recoveries, and for desiring to postpone his operation for a few days in order that his surgeon may be absolutely sure, with the aid of consultants perhaps, that he really has appendicitis and not any cholicystitis, or in the slighter cases, a mere

indigestion. However much the surgeon may desire to meet with his patient's appendix in as good a condition as possible, it is certain that in piactice he will have very few opportunities of removing it in the first few hours of an acute a ttck. -Ihis is particularly true of our Indian pa lents at present. He must then content him- ?

Y1!! w,^c^lng the case until he sees the course which the disease is likely to take. On the one

an, ' |,nay have to deal with a fellow creature sna ched from apparent good health and sent to

e bunk of eternity in a few hours, or he may lave to deal with a little colic, and a little ten- derness which passes away in a few d;iys. In the foimer case his greatest vigilance is demanded 10m hour to hour, sometimes almost from minute o minute. The onset has been very rapid. An acu e pain perhaps situated over the umbilicus, and not necessarily over the appendix, has started the

patient, a vigor follows with rising temperature, a soft pulse rapidly increasing in frequency, and soon vomiting. Then he will be wearing that

anxious indescribable look which tells the surgeon

plainly of some abdominal disaster. In such a

case it is of the gravest importance that the

decision as to operation should be lei tin the hands of the person who is to operate and who should

see the patient's symptoms for himself at short

intervals. A single consultation may just happen to catch the patient in a quiet period, the lull, for example, which follows sometimes the gangrene and perforation of the organ. Some little circumstance may point the way for

action or give the signal for delay, which may be

lost to notice if the watch is not very thorough. The occurrence of an initial rigor is very im-

portant and in the face of a general crescendo of symptoms, the call for operation must not be de- layed. If after a few hours the pulse rate falls and the temperature is less, and the pain diminished without the use of morphia, then in spite of the

initial severity of the attack the surgeon may still wait a little, until further symptoms arise, but unless all symptoms abate in doubtful cases

of this severity, he will do well to operate. The use of morphia in these early stages is a crime. The masking of symptoms until surgical aid is

useless, is the price paid for a few hours com-

parative ease. In a less severe attack absolute rest is imperative. The wisdom of purgation is

challenged. Personally, I pvefer to keep the

milder cases under small doses of laxative salts to

ensure the moving on of the intestinal contents. A small enema too may he carefully given at

intervals. For the pain and colic not fomenta- tions of light material are very useful and com-

forting, but heavy hot water bottles should not be used if the case has not demanded operation in

the first few hours, it may still come to it in the

event of some manifest surgical disaster at a latei stage, when the chances of success are decidedly less favourable. In the less severe type, the

rigidity of the abdominal muscles gradually wears off after a few days, and if there has been marked local reaction the tumour consisting probably of agglutinated intestine and omentum will be felt. It now remains for the surgeon to endeavour to

discover whether an abscess is present or not. I*

fluctuation can be clearlv felt, there is no need of further discussion. In other cases, where onl) the tumour is present, reference must be made to the pulse and temperature as compared with

previous days. The rectal examination which is

indispensable in all examinations, of a suspected appendicitis, may give some information. So too, a blood count, especially a differential count, may give a clue. Muscular rigidity in itself is no

proof of the presence of pus. I recollect a case

in which I was tempted by a "

phantom tumour, i.e., locally rigid muscles, and a high blood count of 18,000, to open the abdomen of a patient, who was suffering from fever and a tenderness over the appendicular region. I must say that

Oct., 1910.] CHRONIC APPENDICULAR ABSCESS. 403

expected to find pus, but found only an appendix, slightly thickened perhaps, but looking to the

naked eye horribly normal. Microscopic section showed ulceration of the mucosa. His pain and fever immediately left him and he was troubled no more by it. The high blood count was subse-

quently found to be due to a miscalculation by my informant, and there was a more moderate count next day. Parenthetically, it may be remarked that " phantom tumours

' of muscle almost always

indicate a deep seated trouble below. When the

surgeon has settled to his own satisfaction that

pus is present, it is safest to evacuate it. The more general course for an unopened appen- dicular abscess to pursue, is to open into the bowel, which I regard as one of the most favourable methods of termination. For reasons which I

cannot explain, there seems to be no tendency for a reflux of bowel contents into the abscess sac.

The abscess seems ordinarily to close up in a very short time considering the size to which an appen- dicular abscess may grow. However, one cannot be certain of this favourable termination. In a few cases, the abscess may burst into the general cavit}' of the abdomen, with disastrous results. On the other hand, an abscess left unopened too long m-.y result in portal pyaemia and liver abscess. The pulse and temperature, blood count and the amount of local reaction will give a fair

guide as to what delay, it any, is permissible in seeking for the presence of pus. The tumour should be very carefully and gently palpated day by day, and its increase or diminution will help to guide the surgeon. I believe that a certain number ?f appendicular tumours which appear to have resolved, have really discharged the contents of an abscess into the bowel. A bov was brought to !ue from a place several hundred miles away, with the statement that a distinguished surgeon had stated that he should be operated on at once. This may have been the case when he was seen

there, but when he arrived under my care, a

jailing pulse and temperature led me to stay mv hand. As the rigidity of his muscles passed iUVay, a, mass was felt on the right below the costal arch, whilst his appendicular region was

jdso tender. He did well for a day or two, but his temperature remained at about 101 or 102. I

concluded that he had an abscess, and gave orders t?r his operation In the night, however, his

temperature fell suddenly to normal, and the 'uass was much diminished in size. The stool which he passed that night was unfortunately brown away. He had no further bad symptom, and 1 expect to remove his appendix by an

interval operation, at a more favourable season. 11 the other hand, shortly before I had seen a

,lrge mass in a similar situation, in the case of 'ln elderly Bengali lady, which disappeared quietly } resolution.

Chronic Abscesses.

..The surgical treatment of these chronic appen- lcular abscesses requires great care. In uiy

own mind, IdivMe them into thr?? ni (1) those in which the abscess J,s?es' viz. :? to the anterior abdominal Wall ?

adherent which there is free peritoneum i?#i ? in

between the abscess mass and fi e7eninJS[ wall ; (3) those which bulge jnto fi10 abdominaI press on the pelvic contents. pelvis, and These varieties all require different treatment

Operation for removal from Abscess Wa,,

'

The first is the most common here T small incision usually over the mn b

'

-USe a

part of the tumour, separating f) ^"?m'nent

fibres, except when they have bee ,nuscu^ai'

the inflammatory invasion, in the <Ln!!n ,"p ^ If more room is needed, I f~n 'r layers. Bowlby's plan of '"."""ff 'he rectus f' A' of its sheath and incising if* n

. Pai out

The deeper layers are carefully'"0r ,a7er- when the presence of pus is pro^d^S?^/11^ director, I enlarge and examine tl

a k'"nt one finger. Caution should be use^ with down trabecular crossing the ab?

? 10 ak*n? these probably contain vessels Cf-\ cav^y as

troublesome. Now the question nfV '

IVa-^ appendix is before us. Again Je,nova' of the Lockwood, I cannot concefve wh

? 0win& Mr.

appendix should be wilfully }eff. ? ^ arJ^ diseased

it can be generally found and *'! U

^ when

perfect safety from this type nf 1^move<^ with The operations should, however on/* iSC0SS cavity. by those with experience in 'nh'l ? attempted Statistics vary ns to the perepnf.?minaJ Work* rences in those cases, in which rer>

lecur-

dicitis occurs after abscess. It ? Ul,eu|j aPPfin- per cent. In the great majority 0f f? 15

cent, the appendix may be removed efpe 15 Per taken. It is true that when the exuni' * C,lre arrives inside the cavity, all inav 'spp!!!"! ^nger blank, but a careful and very o-entla a, a

of every part of the cavity should be ̂ nadT^T only a very small proportion of the cases win tu

whole appendix be felt. Often only a verv l! portion of the organ is in actual rplot*

the abscess cavity. The most comforting Iv ^ to come across the tip of the appendix ?Tl ?

\ ]s like the pulp of the tip 0f a soft mt I ^ fee,s peculiar feeling not easily obtained fmm ?1"01' a

hardened omentum, which most often si! ^|eCes appendix.

1,nulate the

If the tip cannot be felt, it is Weij f

the variations in thickness which f]? 1 e,ne'nber

may present. Working i? ? "1 "M'Pendu with the rij-ht or left forefinger !? Cavi<? the more convenient, the obiect ?

? 11

elver 's

the appendix is gently separatei^^T 6<j t0 entirely at this stage on the sensp nP *. ,el>en(l omentum is attacked by mistake v .

ouc^- If

want of regularity and the absence' nf ^??1]1i^10 feeling of the thickened sub-m?

?

tbe|0?id-Iike coats will show the error. Z?"

'

must be dropped and a fresh careful 0me' t;1g

In a very few cases only the wall, ? '

and smooth that there is absolutely 'i? indi^S

404 THE INDIAN MEDICAL GAZETTE. [Oct., 1910.

us to the position of the appendix after very careful search. In such cases only do I leave the appendix. To continue with the steps for removal from a walled-in abscess cavity, I discard retractors for they hurt the finger, which is at work inside, and while separating the appendix from its bed of lymph, I make no attempt to take up its vessels, unless a

mesentery is clearly seen which is rare. Nothing is more dangerous than to push pressure forceps at random in the hope of checking bleeding in a cavity. The ends of the forceps are sure to nip something undesirable. Fortunately although the haBinorrhage during separation may be a little free, it need cause no alarm. It soon

stops with the pressure of a damp plug of gauze. Next, as forceps in a small wound take up valu- able space, I pass a silk thread round what I take to be the appendix, and pull it up as far as possible to the surface for identification. If all is right, this thread serves to tighten the appendix whilst further separation is effected, and this is continued until the operator has made up his mind that there is no more left, or that he can go 110 further, preferably the former. In some cases the muscular layer is too soft to be dis- sected out entire, and the finger passes between it and the cord-like mucosa and swollen submucosa, which may often be traced much further thau the muscular layer. Wheu possible I apply a ligature to the base of the part separated and use that ligature as a tractor to enable me to make a still further separation. Sometimes the appendix tears through before a ligature is placed round it. This little accident has caused me no trouble. "\\ hen I do eventuall}7 find the ase and ligature it, I leave the ends long enough

to hang out of the skin incision, as I have no

ito leave a sinus which will not heal. Ihe hemorrhage if at all free ceases very soon, especially if a little gauze is pushed into the wound. Io complete the operation, I put a rubber drainage tube and tuck in a little gauze round it, and sew up most of the skin wound. Deep muscular stitches are not used as these would leave sinuses. Ihe deep incision is quite small, only large enough to allow the finger easy access, and there is very little chance of hernia, if the abscess has no invaded the abdominal wall too deeply. In su sequent dressings the gauze is withdrawn on the second day and the tube quickly shortened.

le cavity is never washed out under pressure, hi i foul a little hydrogen dioxide solution is pouied in and sucked dry with a glass syringe, a in la-tubber tube after a short lapse of time, w i s the gauze inserted is soaked in the same so ution. Insoine cases cellulitis spreads along to the lumbar region.

I try and avoid incisions here, if possible, as e connective tissue is so much opened up. Jijxtensions of cellulitis in that direction o,.?.n ,c ?r UP ?fter an abdominal incision.

i _

lumbar drainage may be necessary on occasions. ?

J

(2) Second Form of Abscess.

In the second form of abscess, where free

peritoneum exists between the skin incision and

the abscess cavity, we are face to face with a

much more serious state of affairs. The condition

is sometimes found as a surprise, but may, more

often, be suspected from the ease of movement

of the abdominal wall over the mass and some'

times by the presence of resonant gut between

the abdominal wall and the abscess. In these

eases it is as well to note if there is any possi- bility of establishing retro-peritoneal drainage. As a rule there will be none, as these abscesses

attached as it were to the part wall of the body tire more usually found towards the middle line away from the anterior iliac spine. The situation

is a dangerous one, and should be carefully dealt with. First of all gauze should be tucked all

round the mass, each separate piece having its

end hauging out of the abdominal incision.

When a good layer of gauze is in position all

round, the abscess cavity is carefully opened between two coils of intestine if recognizable, if not, the finger may be used to take tlie line of

least resistance, and the abscess cavity is opened, the pus being mopped up as fast as possible by swabs of damp gauze. When the cavity is

empty a rubber tube should be inserted, and if

soiled, the pieces of gauze acting as a dam may be changed. These pieces surrounding the tube are changed after 24 hours, a process which un-

fortunately causes great pain. On cleansing the next strips need not be tucked in as deeply. In these cases, unless the appendix' absolutely appeared in the abscess cavity, I would not try to remove it, as the less the disturbance of the

parts, the better. In no case should the pus from such an abscess be released until all preparations have been made to sop it up, otherwise severe

symptoms resulting from the absorption of the toxis by the peritoneum may very soon be expect- ed. This class of abscess is naturally dangerous.

The precautions described above will also have to be taken when fouled peritoneum is found during emergency operations for removal of the

gangrenous appendix or when acute abscesses are found.

(3) Pelvic Abscisss. In the third class of abscesses I place those

which are found iu the pelvis pressing on the

rectum, into which, if left to themselves, they would probably burst. Given this condition, the most natural course seems to me to anticipate nature, and open them carefully through the wall of the gut. In this way thev seem to do very well. In one case a boy came to me after a fortnight's fever. His appendicitis first of all had showed itself iu the usual place. On the formation of an abscess, it had tracked over to the leftside, and was clearly felt, in the left hypogastric region. Lt had then invaded the pelvis. In the right hypogastric region it was obviously deep seated. In the left hypogastric region there was plainly

Oct., 1910.] THE INTERVAL OPERATION FOR APPENDICITIS. 405

free peritoneum and the large bowel between

me and the abscess. So declining an invitation to

open the abdomen for safety's sake, I opened the

abscess through the anterior wall of the rectum

and drained it with a rubber tube. All went well

and a large abscess was cured in a few days. There is no necessity to make a second abdom-

inal incision as drainage takes place very well

without it. The appendix can afterwards be

removed by an interval operation.

Self-retaining Drainage Tube.

I have for the last 12 years used a little device

of my own for securing the retention of a

drainage tube in this and similar situations. A

suture through the intestine is thus rendered

unnecessary. A ring is cut oft' the end of the

drainage tube. Two wings are cut in the same

end of the drainage tube, and the ring is passed over them and then under the free end, to make them stand out like flukes of an anchor. So

prepared, a drainage tube never comes out unless drawn out, nor is the ring ever left in. The

diagram appended will, I think, explain itself.

"The Interval Operation." The so-called interval operation may naturally

vary much in its difficulty. Sometimes there will be none. But in these cases and in all others there must be no stump. Incomplete operations like other sins are sure to be found out. I have

recently had in my charge a man suffering for

the third time from appendicular abscess. He

had two scars on his abdomen. One, he said, represented the opening of an abscess, but through the other his appendix had already been removed elsewhere. On opening his abdomen tor the third time I

found a large abscess and was able to remove

inches of a greatly diseased appendix, much to the man's surprise when he heard of it. Believing that in the cuff operation, there is rather a ten-

dency to leave a stump, I prefer to crush with

forceps and ligate, and then to sew the peritoneum, covering the caecum over the ligature with a few stitches. Of course, care must be taken with the

vessels in removing the free appendix, for here the conditions are widely different from those in which the appendix is grubbed out from the abscess wall. One little \essel at the base of the appendix needs especial attention. Interlocking ligatures will

Probably afford the best protection against hsemor- rhage. Care too must be taken to change instru-

ments which have been used for fi,~ i

division of the appendix, and if ? 'TIT iicid is used for the '

stump,' it must mf car, !lc used neatly and not allowed to treats y

More than one consideration fIlo ,

Uon of the length of the intervafbZ^?; In the first place, f the initial attack has been severe, and there have been definite si?ns of peritonitis, it will be better to wait for some con- siderable period, unless there are contraindications I operated on such a case three weeks after the a tack, sooner than I wished, but ??der uuavoi(,! able circumstances. I here Vvi<? fl>? ,

difficulty in recognizing the parts 11 ,?ieatest i i i 11

as all the co x ot gut. large and small, werp i . ,

thick veil of inflammatory exudation I finally

X and of t/e these conditions was considerblv Ie?l i

? V" '1

found that only the thinnest of inS^' when 1 tected the patient from another nn

' ^ J,ru"

attack. Had I been able to wait C 7 ^ there might have been very fevv adhesioL?0 Th?' case, however, brings me to the sprrm l

'

-j

Uon No one is "safe, if Xf mf aZf Tb" tenderness persists, or the temnp,-. t-

'

?

above normal, or if the ton J ' re. cellent index of appendicular heiltb

GX-

become clean. At such times it will '1 1 uses to

better to hasten the operation 'and nnf ? P10 a^b*

state of things dangerous to the 1

f P *? 11

ing to the surge on! Another^ttthTch me is, that it an abscess has ri^i stJikes through the bowel, this fact must hp1<l/? ^seJf consideration, as if the appei dL?? laken '"to

taken too early, there must be a

' 3'-'S "1de''-

producing a fecal fistula. I? "Sk of

interval of a few weeks has beeu suffi^ient^T?'1 point of discharge into the gut need not be near the appendix itself. It is of course a troublesome and dangerous complication to come acr unsuspected or half-healed abscess in fi,?

0;sS ''U

of an " interval "

operation. tbe COUr*e

Transport of the Patient The (juestion of transporting cases of annenrl;

citis is sure to arise in this country. ]-fer every case must be judged on its merits early stages, nil movements and consequent)!! n

travelling must be dangerous. If there '

1 ?

reaction, and arrangements can be 6 ^

comfort, it is possible that patients nnv i" e *or

later on. Cases of this description h?> 6 m?_ved me in perfect safety, though without^?'1 vious knowledge, irom places as far j;.i. f Pe~

Calcutta as Waltair and Benares hnf *1 ' ^ro,n

be a certain amount of risk in uiovinrr 1<3\e must to0.

"uving such cases

I fear that there are numprnn* ? i

points upon which I have not been im",erestl.ng but I hope that these remarks nmv l*3 Vvnte> use to the junior members of our . r ?

some

whom the care of these cases may fjj] ? ession? *?

The writer's method of making a self- retaining drainage tube.

The writer's method of making a self- retaining drainage tube.