In performing the operation the smallest possible incision should be made through which the appendix may be delivered, its mesenteric artery is tied, and its mesentery stripped down to its origin. At the latter the cecum is fastened to the parietal peritoneum by a suture on either side, avoiding the appendicular artery itself. The balance of the wound is then closed as usual, the appendix being fastened to the lower angle by suture, the protruding part then wrapped with gutta-percha tissue and included in the dressing. At the end of two days the external portion may be divided about 1 to 4 inches from the skin, after which a catheter is passed along its lumen and the stump tied around it. This serves the double purpose of preventing leakage and severing the appendix flush with the skin. The catheter is introduced from 2 to 4 inches, and its external portion left open to allow escape of gas, or doubled and fastened to prevent leakage, as circumstances may require. Irrigation may be begun on the third or fourth day.
When the appendix is used for the purpose of forming an artificial anus it will be probably in instances where there is more of the emergency element present, and it may be sufficient then to simply utilize it for the purpose of anchoring the cecum to the abdominal wall, or with the purpose of dilating it after the expiration of a few hours. In other words, the method may be modified to meet the indication.
It is scarcely necessary to devote space to any other operative procedures upon the small intestine. Consequently it will simply be mentioned here that the upper part of the jejunum can be used for artificial feeding and jejunostomy made to take the place of gastrostomy under those rare circumstances which may demand it.
Upon the large intestine colopexy may be practised, attaching it to the anterior abdominal wall or to the border of the liver or the gastrohepatic omentum. Andrews’ suggestion to attach the colon to the lower border of the liver, after certain operations upon the biliary passages, will be described in connection with the latter. In cases of extreme dilatation, with loss of muscular tone, etc., involving especially the colon, an enteroplication may be practised corresponding to gastroplication, and having the same purpose, with a technique practically identical with the other. Thus when the sigmoid flexure is so dilated as to largely fill the abdominal cavity, with an enormous S-shape, much can be done by thus reducing its dimensions, the only objection being the fear that the causes which produced the condition will conspire to reproduce it even after enteroplication.
CHAPTER XLIX.
THE APPENDIX AND ITS DISEASES.[59]
[59] The laity, as well as part of the profession, having not yet ceased to wonder at the great importance attaching today to appendicitis, when twenty years ago it was practically unknown, it is worth while to insert here the following brief historical account: The term “appendicitis” was coined by Fitz for a condition which had not been hitherto unknown, but to which he gave a classical description. That the appendix might be primarily diseased had been known for one hundred and fifty years; that peri-appendicular abscesses were frequent may be seen by reference to works of the middle and latter part of the past century on perityphlitis and perityphlitic abscess, Willard Parker, of New York, being the most prominent writer of his day upon this subject. In the Transactions of the Medical Society of the State of New York for 1875, Gouley reports a case of so-called perityphlitic abscess due to perforation of the appendix, with remarks upon its surgical treatment. The curious feature attaching to this case was that two years previous to its occurrence the patient had swallowed one of his teeth. Although this tooth was not found at the time Gouley alluded to the possibility of it or any other small body lodging in the appendix and finally causing ulceration. He referred also to the case published in 1856 by Dr. Lewis, of New York, who reported an individual dying at the age of eighty-eight, whose appendix was found to contain one hundred and twenty-two deer shot, it appearing that he had been exceedingly fond of game; he supposed that the shot found in the appendix were contained in meat which he had eaten. Lewis also referred to forty-seven cases of foreign bodies which he tabulated, all but one of which died.
Fitz’s article appeared in 1886. In it he claimed that operation should be done much earlier than was then the custom, and he showed that 34 per cent. of these cases died during the first five days of illness. But the first real operation for appendicitis as such was done by Krönlein, of Zurich, according to a suggestion made by Mikulicz in 1884. The second was done by Symonds, in England, in 1885, this being an interval operation. The first operation in the United States was done by Hall, of New York, in May, 1886, although to Morton, of Philadelphia, the credit must be given of the first operation in this country on a case deliberately diagnosticated. This was in April, 1887, Sands doing the next one in December of the same year.
McBurney had assisted Sands in a large number of cases, and in 1889 published his classical paper with an account of “The First Recorded Case where an Acutely Inflamed Appendix had been Removed while Full of Pus.” In the same year Weir also published an elaborate paper, making similar recommendations. It is not necessary to follow the subject later than the year 1889, since to it every surgeon of note has probably contributed.
Anatomy.
—The vermiform appendix is an embryonic relic, and, like all such remains, is not merely superfluous, but often troublesome. That at some time it may have had an ordinary function is not to be denied; that now, in quadrupeds at least, it has one cannot be successfully maintained. Its past importance may, however, be perhaps indicated by the fact that in the ostrich, for instance, it is said to assume a length of six feet. Because of its relatively wide variations in size, length, and emplacement, as well as because of its mesenteric and other anatomical arrangements, its affections are often complicated and variable in the symptoms they produce. The appendix is, in fact, a miniature intestinal tube, having the same structure as the small intestine, though but greatly reduced. Its average length should be 8 to 9 Cm., the shortest on record being 1 Cm., and the longest perhaps 24 Cm. Its average gross diameter should be that of a No. 16 French catheter, but it may be found 1.5 Cm. in size. The average diameter of its lumen should be 1 to 3 Mm. The appendicular artery is given off from the right colic branch of the ileocolic artery, and it ordinarily divides into four or five branches, according to the length of the appendix and the extent of its mesentery. It derives its nerve supply from the superior mesenteric plexus of the sympathetic ganglia, which itself is connected with the right pneumogastric, this fact explaining many of the reflexes accompanying its diseases. In it lymph abounds and lymph follicles are numerous. Around its neck, as around the origin of every other embryonic canal (as Sutton has shown), is found a collar of lymphoid tissue corresponding in structure to that seen in the pharynx. This tissue is inflammable, and succumbs easily to infection. Hence probably the apparent ease with which infection and gangrene occur in this locality. The position of the appendix is variable, and depends in effect on the development of the cecum and the degree of its rotation during this process. Its most frequent location (40 per cent.) is behind the cecum. In 30 per cent. of cases it occurs on its anterior surface or just at its lower end. It may lie as a free pouch with a loose mesentery, movable in the abdominal cavity, or it may be essentially a retroperitoneal affair not only not free, but even difficult to find. In direction it may vary correspondingly. Thus it may lie behind the colon, perhaps pointing straight upward toward the liver; it may hang in the pelvis, it may point toward the sacrum, or it may coil up anteriorly; and, according to the extent and freedom of its mesentery, in any of these locations, it may either be unattached and movable or quite bound down. Again, it may lie nearly straight or it may be kinked, bent, or coiled. It is necessary that the surgeon appreciate these possible variations, for they account for vagaries in symptomatology. In brief it should lie in the iliac fossa, at least, and to the outer side of the iliac vessels, but it may hang over into the pelvis in 20 to 25 per cent. of cases, or its tip may rest in a pocket or even in a subcecal fossa. In other words, it may be found in almost any attitude or position, these variations being explainable by peculiarities of fetal development. Furthermore it may even have its own diverticula, as has been recently shown. Normally it should be practically empty, save perhaps for a little muddy mucus. Very frequently, however, it contains fecal matter, and upon this fact depends much of its importance. If from retained fecal matter fecal concretions gradually result, then these become irritants and may produce either appendicular colic or may predispose to acute infection. Upon the retention of fecal contents should depend also a miniature peristalsis, and imitation of what goes on in the intestine above, in the production of a genuine appendicular colic. How annoying, painful, or even disabling this may be may be learned from the history of many a patient. On the other hand the appendix may become gradually occluded or obliterated, in whole or in part. If this process begin at its distal end and involve the entire tube it might be considered a fortunate occurrence for the patient. If, however, it be due to previous inflammation, or to subinvolution of the previous process, and if fecal concretions be thus imprisoned, it is hardly desirable and will frequently lead to trouble. More or less occlusion occurs in probably at least one-fourth of mankind.