In the chronic form of the disease though the patient is never desperately ill he is never quite well. He has pains and discomfort in the abdomen, with slight tenderness and nausea, with “indigestion,” as he may call it. And as one can never tell when the smouldering inflammation may break out into conflagration, he is well advised to submit himself to operation without further delay. To carry about a diseased appendix is to run the constant risk of being laid up at a time most inconvenient, as when travelling or when staying in some place where skilled assistance is far distant or absolutely unobtainable. But having made up his mind that the appendix had better be removed, the patient can choose time, place and surgeon, and, having undergone a week’s careful training for the ordeal, can safely count on being back at work again in a month or six weeks’ time.
As regards treatment, the greatest safety consists in the prompt removal of the inflamed appendix, and statistics show that if the operation can be done in the first or second day of even an acute attack, the result is generally favourable—that is to say, if the appendix can be removed whilst the disease is still shut up within its tissues. But in some cases ulceration and perforation, or mortification, may have taken place over a hard faecal concretion within the first twenty-four or forty-eight hours, and, the septic germs having been let loose, peritonitis may have already set in, and operation may be followed by disappointment. Still, if the case had been left unoperated on, no other result could have been expected. It was not to the operation, but to the intensely acute disease that the calamity must be attributed.
Nature is marvellously clever in some of these cases in shutting off the area of the disease by glueing together the neighbouring coils of intestine, the limited local peritonitis causing the tissues to build themselves into a wall which securely shuts in the abscess cavity. But in other cases she seems helpless, no barrier being formed for limiting the area of disturbance. In such a case it is inevitable that disappointment must result from the surgeon delaying operation in the hope that delimitation might take place. And when at last he makes his incision he sees that the disease has had so long a start that his own chance of success is but a poor one. In a less severe attack, under the influence of rest, starvation and fomentation, and in cases of chronic and of relapsing disease, the surgeon may watch and wait and choose his own time for operating. But when the symptoms are steadily increasing in severity he should urge an immediate incision. When, as often happens, the inflammation begins suddenly and severely, and, under the influence of treatment, steadily quiets down, the surgeon does well to delay operation. But in a fortnight or so, when everything has become once more quiet, he will urge the removal of the appendix, for this one attack is more than likely to be the forerunner of other attacks if the diseased appendix is left.
The most serious cases are those in which the aspect, the pulse, and the temperature of the patient fail to give warning of a very advanced state of disease. Every surgeon of experience has met with cases in which, though there is nothing pointing to the fact that the patient is on the brink of a disaster, the operation has shown that the appendix is mortified, and that it is surrounded with abundant foul matter. It is then that he regrets not having operated a day or two earlier. Consequently it is a good rule to operate in all doubtful cases. In cases in which one happens to know that previous attacks have passed off under palliative treatment, there is no need for immediate operation; the quiet interval may be safely waited for. But in cases in which there is “no history,” and in which the surgeon has nothing to guide him, the greatest safety is in prompt operation.
If an attack of acute appendicitis is allowed to take its course unoperated on, abscess forms in the peritoneal cavity in the region of the appendix, but if already inflammation has happily glued the intestines together around that area, the pus is confined within definite limits. But as the abscess increases in size the demand for its evacuation becomes urgent. The pus, under the influence of a natural law, seeks its escape by the path of least resistance; sometimes this is into the intestine, and occasionally into the bladder. The most satisfactory course which it can take is through the wall of the abdomen and out above the right groin. As it is making its way in this direction the skin over that part becomes red, swollen, hot and tender, and the tissues between it and the skin become swollen and brawny. Rarely is fluctuation to be made out until the pus has worked its way close to the surface. Later, ulceration takes place in the undermined skin, and the stinking contents of the abscess escape, greatly to the relief of the patient. But long before this could happen the surgeon should have made an incision through the inflamed tissues in order to give nature some greatly needed help. For in many cases she allows the pus blindly to discover that the course of least resistance is not towards the surface of the abdomen but through the inflammatory barrier formed by the adherent coils of bowel, and so into the general peritoneal cavity. This unfortunate issue may give temporary relief to the patient, so that he says that he feels much better, and that his pain has nearly gone. But though his temperature may fall, his pulse is apt to quicken—an ominous coupling of symptoms; the paralysed bowels become further distended, so that the lungs are pressed upon and breathing is embarrassed; hiccough comes on; and whether operation is now resorted to or not, a fatal end is highly probable. In other cases, the escaping pus finds its way up towards the liver and forms an abscess below the base of the lungs.
If operation is performed when appendicitis has run on to the formation of abscess, and the diseased appendix presents itself, it should of course be removed; but if it does not present itself the surgeon should abstain from making a determined search for it, as in so doing he may break down the barrier which nature has provided, and thus himself become the means of spreading a septic peritonitis. Nor should he attempt to make clean the foul abscess cavity. All that he should do is to provide for efficient drainage. A large proportion of these cases do extremely well with incision and drainage, and in the subsequent healing of the cavity the wreckage of the appendix either undergoes disintegration or is rendered harmless for further anxiety.
In some cases, however, the damaged appendix remains as a smouldering ember, ready at any moment to cause further conflagration. This is made manifest by lingering pains, and by tenderness and warnings after the abscess has healed, and the patient will be well advised to have what is left of the appendix removed by operation at a time of quiescence. The operation, however, may turn out to be a very difficult one. Sometimes the wound by which the abscess has been evacuated, by nature or by art, refuses to heal completely, a little discharge of a faecal odour continuing to escape. The small wound leads into a faecal fistula, and a bent probe passed along it would probably find its way into the bowel. The wound is likely to close of itself in due course; but if after many weeks of disappointment it still continues to discharge, the surgeon may advise an operation for its obliteration.
It occasionally happens that after operation the scar of the wound in the abdominal wall yields under the pressure from within, and a bulging of the intestines beneath the skin occurs. This is called a ventral hernia, and if the patient cannot be made comfortable by wearing a truss with a large flat pad, an operation may be deemed advisable.
If, in a case of appendicitis, for one reason or another operation is to be delayed, what treatment should be resorted to? The patient should be put to bed with his knees resting over a pillow, and a large fomentation under oil silk should be laid over the lower part of the abdomen. No food should be given beyond an occasional sip of hot water. Purgatives should not be administered, as this would be to set in movement an inflamed piece of bowel. If the case is not acute, a large enema of soap and water with turpentine may be given, or, possibly, a dose of castor oil by the mouth. As a rule, however, it is unwise to set the bowels in vigorous action until the diseased appendix has been removed. No opium should be given.
Acute intestinal obstruction, cancer of the intestine, inflammation of the ovary, typhoid fever and renal and gallstone colic, are affections which are apt to be mistaken for appendicitis. The first of these resembles it most closely, and diagnosis is sometimes impossible without resort to operation. And it is a fortunate thing that, when error of diagnosis has been made, the operation which was designed for dealing with an inflamed appendix may be directed with equal advantage to the morbid condition which is found on opening the abdomen. In typhoid fever the characteristic temperature, the general condition of the patient, and the presence of delirium are differentiating signs of importance; in renal and gallstone colic the situation and the more paroxysmal character of the pain are usually distinctive.