There is scarcely any equally limited area of the body in which as many varied and widely different pathological conditions may be exemplified as in the appendix and the space immediately around it. The mildest degree of hyperemia or vascular engorgement, the most destructive form of inflammation, with fulminating necrosis, may here be observed. Moreover, conditions commencing under one type may quickly change and the whole type of an attack may within a short time be merged from the mildest into the most severe.
In catarrhal or endo-appendicitis it is mainly the mucosa which suffers. This may undergo merely a congestion, with increase of discharge, and, so long as the outlet be not completely obstructed, may be a purely temporary matter of but a few hours’ duration, or it may extend over a few days. The purulent or more destructive forms may commence in either of the coats of the appendix. It is no uncommon thing to find a necrotic mucosa with a still unbroken serosa, or a perforation of the outer coats and a hernial protrusion of the inner, perhaps just ready to give way. In location and extent the suppurative and destructive process may also vary. Whereas ordinarily the distal portion, being less supplied with blood, will suffer first, it is not uncommon to find perforation at the junction of the appendix with the cecum, or even gangrene of a limited area of the cecal wall itself. Again, at times, the trouble seems limited to accumulation of pus within the appendix, i. e., an empyema of the appendix, without great tendency to involve the structures adjoining, and an appendix may be found containing a few drops of pus or distended almost to its bursting point still free or but slightly attached by exudate. In the milder cases there may be found strictures indicating the site of previous lesions. Again, aside from pus, there may be more or less fluid or semisolid fecal matter or dense concretions, in addition to the possible foreign bodies whose presence has been elsewhere considered. In the more subacute or chronic forms there will be found relics of previous rather than active expressions of present trouble, such as strictures, thickenings, contortions, old adhesions, sometimes quite dense, and contained concretions, or other foreign bodies, or one may find appendices shrivelled up or more or less obliterated (appendicitis obliterans).
The role of the omentum has elsewhere been mentioned, but must be alluded to again at this point, since it participates more or less in almost every case of acute appendicitis. The moment the appendix is acutely inflamed the omentum tends to shift itself over toward it and finally around it, and it is not uncommon to find a gangrenous appendix wrapped in a roll of this kindly disposed fatty apron. In fact this may constitute the tumor which may have been already discovered and found to be fixed or movable. The inner surface at least of the omentum thus applied will nearly always have sacrificed itself and one has need usually to remove a considerable area of gangrenous omentum, as well as the appendix itself, feeling as he does it that he is necessarily sacrificing the best friend that the incriminated appendix has had.
Aside from what may concern the appendix itself the two most serious complicating local conditions are abscess and gangrene with perforation. Abscess is not necessarily the result of perforation, at least at first, but may be due to infection by continuity, the sequence of events being acute appendicitis, with exudation, fixation, and adhesion of surrounding tissues, followed by pus formation, perhaps first within the appendix and then perforating, or perhaps having its origin in the infected exudate exterior to it. So long as this process is localized by a protective barrier of surrounding lymph, with intestinal adhesions and the assistance of the omentum, there is to be dealt with a more or less complicated peri-appendicular abscess, such as in the past was frequently seen and spoken of as perityphlitic. Concerning the frequency of perityphlitic abscess in days gone by the literature of the previous century will afford ample illustration, but in spite of the surgical acumen and advice of Willard Parker, who taught the profession how to deal with it, its proper explanation did not come until the researches of Fitz, alluded to at the beginning of this chapter. Even now it is perhaps not quite correct to say that every typhlitic abscess, i. e., every collection of pus around the typhlon or head of the large intestine, is of appendicular origin, for the tendency has been to forget the possibility of phlegmonous cellulitis about any part of the bowel without reference to the appendix.
Such a peri-appendicular abscess may be small, containing but a few drops of pus, or extensive, even to the degree of holding a pint or more. The pus is usually offensive and sometimes one will find floating in it shreds of tissue, or even a completely separated and sloughed-off gangrenous appendix. According to the original location of the appendix, and the disposition of the adjoining parts, such a collection of pus may form a tumor in the iliac fossa, which may also fill the pelvis, or may present in the loin, closely simulating a perinephritic abscess.
It is unfortunate when the natural walling off process has failed and we have to deal with a spreading, generalized, septic peritonitis. A partial compromise between these conditions sometimes appears as a widespread yet practically localized peritonitis, in which several loops of bowel have become affixed, and, what is worse, infected to such an extent that they are themselves breaking down, so that there may be impending or actual gangrene of the intestine. Such a condition bespeaks the intensity of the infection and the destructiveness of the infectious process, and produces a condition which may appall the operator. The result is not only acute obstruction of the bowel but such a local condition that one scarcely knows where to begin or terminate his operative efforts. It was in such a case as this that I removed eight feet and nine inches of bowel, the last nine inches including the colon, turning in both ends and making a lateral anastomosis, because of multiple gangrenous patches, each of which taken alone would have required a distinct and laborious intestinal resection, it seeming better to remove the entire amount involved. This patient recovered and was well years after the operation. Still other complications may disturb the surgeon’s calculations. Thus fecal fistula may have already occurred, or suppurative thrombophlebitis may have already produced the beginnings or an hepatic abscess, while septic expressions within the lungs, the heart, or elsewhere may have also occurred. In addition to this general peritonitis, with all of its terrors, may put a hopeless aspect upon the case.
Treatment.
—Viewed in the above light it will be seen that appendicitis is essentially a surgical disease, and that while mild attacks may at times be successfully conducted to resolution, or tend in that direction without treatment, the danger of spreading infection with all its possible disasters is ever present, and even a mild case is at no moment free from the danger of becoming acute. Considering its widest relations, and believing in the greatest good to the greatest number, the surgeon may easily maintain that, save when it is too late, it is never a mistake to operate, providing operation be properly performed. This, however, is sometimes out of the question, and the laity occasionally assume responsibility for a decision against the better judgment of the profession. We have to accept, then, the fact that, no matter what the theory may be, we are not always allowed to operate when we desire. Nevertheless if a universal rule could be established it could be laid down in terms such as these, that more lives would be saved by operating upon every case of appendicitis as soon as the diagnosis has been made or even in the presence of good reason for suspicion.
With conditions such as they are, and the fact that these cases are usually first seen by general practitioners whose surgical judgment has not been cultivated, and whose prejudices often actuate them, it may be said that every case should be seen early by a surgeon, no layman and no ordinary practitioner of small experience being in position to assume responsibility for delay. It then remains for the judicious and competent operator who may see such a case early, as thus advised, to study it carefully in order to convince himself whether there be about it good and sufficient reasons for not operating. The most honest operator does not gainsay the possibility of mild cases recovering without operation. He does, however, question by which course they run greater risk.
The following may serve as a brief summary of conditions which justify waiting: