Spring 1998, Vol.5, No.1 Experience with Early Operative Interference in Cases of Disease of the Vermiform Appendix Charles McBurney, M.D, Visiting Surgeon to the Roosevelt Hospital I venture to introduce once more the subject that has been so ably treated by numerous writers, because I have for some time been devoting my attention in suitable cases to a particular line of treatment, and because I have been fortunate enough to have had recently a considerable number of cases of disease of the appendix under my care. Nearly two years ag o the account of a case of successful laparotomy for perforation of the vermiform appendix was read before the society by our much-lamented colleague, Dr. Henry B. Sands. The case was a most brilliant one throughout, and illustrated particularly well the cleverness of diagnosis and the rapidity of successful action which we all remember as so characteristic of the reader of that paper. ... During the following months Dr. Sands devoted much attention to this study, and it was my privilege to assist him in a number of successful operations for the removal of the appendix at an early stage of the disease. It seemed to me that each one of these operations shed a flood of light upon the pathology of the so-called pericaecal inflammations, and during the summer following, while discussing the subject, he expressed to me views which were far in advance of most surgeons and very different from those which he entertained at the time when he wrote his last paper. If he were here to-night he would, by the results of his own last year's original work, enlighten us upon many points respecting the pathology of perityphlitis. I feel it a pleasure and a duty to thus refer to Dr. Sands, because, unfortunately, no special record has been kept of his last year's brilliant work, and his sudden death prevented him from telling us himself what would have been so valuable. Certainly no other surgeon ever did so much to improve the treatment of a very fatal disease... Figure 1: Dr. Charles McBurney, distinguished graduated of the Columbia College of Physicians and Surgeons, operating at the Roosevelt Hospital, Ninth Avenue between Fifty-eighth and Fifty-ninth streets. The photograph was taken by Byron in 1900. It is not my intention in this paper to attempt to present the subject of pericaecal inflammmations in a systematic manner. That has already been done, and very recently, by a large number of writers. I have chosen rather to dwell upon some points in the pathology and treatment of these inflammations, which are beginning to be better understood and which especially interest us all. The fact that inflammatory affections of the vermiform appendix give rise to a considerable number of the so-called pericaecal inflammations is now accepted in every part of the medical and surgical world... In (several) early operations I have found a very varied condition of the appendix and its surroundings, from a mild catarrhal condition of the mucous membrane accompanied by some infiltration and thickening of the submucous and other tissues, to the state of complete gangrene of the whole organ, with more or less extensive peritonitis. The pathological conditions of the appendix, as compared with the symptoms in my own cases, most positively show that one can not with accuracy determine from the symptoms the extent and severity of the disease. I therefore doubt the safety of the advice given by several recent writers, to watch the symptoms and to be guided by their violence in determining the method of treatment. ...One patient, who died on the third day from violent septic peritonitis from perforation, complained of comparatively little pain even when the iliac fossa was firmly compressed. The exact locality of the greatest sensitiveness to pressure has seemed to me to be usually one of importance. Whatever may be the position of the healthy appendix found in the dead-house and I am well aware that its position when uninflamed varies greatly I have found in all of my operations that it lay, either thickened, shortened, or adherent, very close to its point of attachment to the caecum. This, of course, must, in early stages of the disease, determine the seat of greatest pain on pressure. And I believe that in every case the seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus. This may appear to be an affectation of accuracy, but, so far as my experience goes, the observation is correct.* I think that there is still much misapprehension in the minds of many practitioners as to the symptoms produced by perforation of the appendix. Many associate with this condition, and with no other, a very violent onset of the disease with quite well-marked symptoms, as compared with the less severe commencement of a slowly forming abscess. The truth is that, in the early stage, no accurate diagnosis can be made as to whether the appendix is perforated or not, excepting in those cases where comparitively mild symptoms suddenly become much aggravated, when perforation or the rupture of an abscess may be inferred. Perforation often occurrs with but few symptoms at the very beginning of the disease, but, being preceded by the formation of more or less plastic adhesion of the appendix, no sudden increase in the severity of the disease occurrs at all. An abscess slowly forms, which may increase to a considerable size without being discovered, and then force its way, or proceed by infection, in the most dangerous directions. The comment might fairly be made upon this description of the early symptoms of appendicitis that the diagnosis of the disease is very obscure and uncertain. To the careful observer it is not difficult, however, to determine as to the existence of the disease. The only real difficulty lies in determining within the first few hours what the future progress of the disease is to be in deciding whether firm adhesions are forming, which will effectually exclude pus from the general peritoneal cavity, and so provide for subsequent safe evacuation of abscess, or whether no such protecting wall exists, and an overdistended appendix threatens to instantly set up a fatal peritonitis. ...No one will dispute that if we could so improve our methods of diagnosis that we could recognize within the first few hours the serious nature of many cases, we would operate in these cases at once, willingly preferring to incur the risks of an operation rather than face the certainty of death that septic peritonitis implies. How may we improve our methods of diagnosis? At present I see no clearer road than the exploratory incision permitting a direct inspection of the parts and a complete study of the disease. If it can be shown by future experience with improved methods of operation, and and with more perfect antiseptic precautions, that the exploratory incision for inspection of the diseased appendix is much more free from danger than the expectant treatment, then there could be but one answer to the question, What is the best treatment? The firm conviction that very early operation for the cure of appendicitis can, with proper care, be done with very slight risk, has induced me to subject a considerable number of these cases to the earliest operation possible, and my chief purpose to-night is to present to you the results of my work in this direction.... Case I. E. M. P., a young gentleman nineteen years of age, complaint of general abdominal pain at 11 A. M. on May 21, 1888. The pain was regarded as due to indigestion, and was treated with family remedies. In the afternoon the patient fainted, and by four o'clock his pain had greatly increased in severity. He received a little morphine and hot applications were applied. At 5 P. M. his mouth temperature was 98.4, his pulse 100. During the night and the following day the patient complained sometimes of severe pain, and occasionally felt much better; he took a considerable quantity of milk, and at 8 P. M. his temperature was only 100. During the second night he suffered much pain, and at 5 A. M. on the 23d it was noted that his pain was chiefly in the right iliac fossa. At 5.30 he had a severe chill and his temperature rose to 103, his pulse to 120. At this time he was visited by his physicians, Dr. Fessende N. Otis and Dr. William K. Otis, who diagnosticated him at once acute appendicitis, and requested me to see the patient. This I did at about 8.30. I found the pulse and temperature as stated, and the following condition: Great rigidity of right abdominal muscles; exquisite tenderness on pressure at a point just two inches internal to the anterior spine of the ilium, in the direction of the umbilicus. Beneath the finger at this point could be felt a small resisting mass, less than one inch in diameter. No dullness on percussion anywhere. General appearance excellent. The diagnosis of appendicitis already made by Dr. Otis was confirmed by myself, and an hour later by Dr. Sands. Immediate operation advised and accepted. General appearance of patient excellent. It should be noted that at 11.30 the temperature had fallen to 101. Operation at 12 o'clock, just forty-nine hours from the first pain. Present, Dr. F. N. Otis, Dr William K. Otis, Dr. L. R. Morris, and Dr. Tuttle. Ether anaesthesia. A slightly oblique incision four inches and a half long, the center of this incision being two inches from the anterior iliac spine toward the umbilicus. Tissues of the abdominal wall quite markedly oedematous, particularly near the peritonaeum. On opening the peritonaeum freely, the appendix came at once into view. It was larger than a man's thumb, dark-brown in color, tense, evidently full of fluid, and at no point gangrenous, but its wall evidently nearly as thin as paper. A tail of omentum partly enveloped it, and this was much inflamed and partly adherent. Everywhere else the peritonaeum was healthy, and not an indication of the formation of any bounding wall of adhesions existed. Coils of small intestine surrounded this full-to-bursting sac. The omentum was greatly separated and the inflamed portion ligated and cut away. The mesentery of the appendix was carefully tied in sections, and the base of the appendix dislodged from an inverted pouch of caecum, ligated at its base, and cut away. It proved to contain at least half an ounce of very foul brown pus, but no concretion. Its communication with the caecum was closed by stricture, so that the unbroken, purulent, acutely inflamed cyst was removed entire. The stump was disinfected with 1-to-1,000 bichloride solution. Two silver-wire sutures passing through the whole thickness of the abdominal walls closed the upper part of the wound, and one similar suture the lower part. The central portion was loosely packed with iodoform gauze down to the ligated stump. Dressing of iodoform and bichloride gauze over all. At 6.40 P. M., less than six hours aftre the operation, patient's temperature was 99.8 and pulse 80. A small quantity of morphine was given for wound pain. The dressings were changed on the third day, and a perfectly aseptic condition of wound found. This patient made a rapid and absolutely unbroken recovery, and is to-day perfectly well. This is, I beilieve, the first recorded case where an acutely inflamed unruptured appendix has been removed full of pus. Who can doubt what the result would have been in this particular case had the cyst ruptured, and the operation been delayed for a few hours? Would not the opportunity for recovery have been lost had the advice so often and so recently given been followed to delay operation until symptoms of spreading peritonitis appeared? Case II.John S., ten years of age, was admitted to my care at Roosevelt Hospital on August 19, 1889. He gave no history of previous attacks. A week ago he became ill, and complained of general abdominal pain. He went to bed, and says that since that time he has been feverish and has not been free from pain. Four days ago the chief seat of pain is said to have been in the right side and low down. On admission his pulse was 110, his temperature 103.4, and he was nauseated. Between the umbilicus and the right iliac spine was noted a considerable tumor, which was markedly tender on pressure. The percussion now over the tumor was dull. No tympanites existed. The general appearance of the patient was that of severe illness. I operated on the same day. The usual incision was made, and the tissues found in normal condition down to the peritonaeum itself was perfectly uninflamed, and uninflamed small intestine covered the anterior face of the tumor. When these were drawn toward the median line, a mass of adherent intestines was disclosed, which inclosed a small indurated tumor. The intestinal coils were gently separated on the anterior face of the tumor, and several drachms of faecal pus at once escaped, emptying a cavity somewhat tubular in shape and large enough to admit a finger. The appendix lay in this cavity, congested, much swollen, and infiltrated with pus. No perforations existed, and no concretions were found. The appendix was tied off with silk and removed. A rubber drain was introduced, the cavity packed with iodoform gauze beside the drain, and a full antiseptic dressing applied. On the following day, August 20th, the boy's temperature was 99.6 as against 103.4 of the day before, a reduction in less than twenty-four hours of nearly four degrees. This patient recovered rapidly and completely, and on September 25th his wound was entirely healed. Case III.W.K., a male, sixteen years of age, was admitted to my care at the Roosevelt Hospital on July 26, 1889. Previous history negative. Forty-eight hours before admission first felt pain in the right iliac fossa. On the next day diarrhoea set in; abdominal pain was quite general, though more distinctly localized in the right iliac fossa than elsewhere, and this increased up to the time of admission to the hospital. The patient's temperature was then 102, his pulse 110. The abdomen was slightly distended and tympanitic. In the right iliac fossa was found a small, very tender non-fluctuating tumor, which lay just inside of the anterior iliac spine. Diagnosis, acute appendicitis. Operation at 3.30, July 26th. The usual incision was made. Beneath the incision were found normal non-inflamed intestines. These were drawn toward the median line, when the appendix was found projecting stiffly forward and slightly upward by the inner side of the caput coli. It curled around the end of the caecum and then turned upward and forward. Slight recent adhesions tied the appendix at its base only to the caecum. At other points it floated freely among non-inflamed intestines. The adhesions were broken down and the appendix ligated at its base and removed. It was six inches and a quarter long, oedematous, and much thickened and inflamed throughout. Minute foci of pus were scattered through its substance, but there was no concretion and no perforation. On its removal the seat of operation was left perfectly clean, but, to insure safety, a rubber drain was passed through the loin directly to the base of the stump, and the anterior wound was partly closed and partly packed with iodoform gauze. The next day patient's temperature was 100. His wound was inspected, but not dressed completely until July 30th. No pus was found. This patient made an unbroken recovery without incident, and his wounds were completely healed on August 19th. ...Before descrbing the steps of the operation, I refer again to the important aid to diagnosis of which I have already spoken namely, the ascertaining, by the pressure of a single finger-tip, that the point of greatest tenderness is, in the average adult, almost exactly two inches from the anterior iliac spine, on a line drawn from this process through the umbilicus. Much greater tenderness at this point than at others, taken in connection with the history of the case and the other well-known signs, I look upon as almost pathognomonic of appendicitis. This point indicates the situation of the base of the appendix, where it arises from the caecum, but does not by any means demonstrate, as one might conclude, that the chief point of disease is there. The abscess, or concretion, or cyst may be at quite a little distance, but the greatest pain, on pressure with one finger, will be felt at the point described. The incision should be a liberal one, for much room may be required, and a five-inch cut in the adult is not too much. It should follow as nearly as possible the right edge of the rectus muscle, and the center of the incision should lie opposite to or a little below the iliac spine, on a line drawn to the umbilicus. When the external oblique aponeurosis is cut through by this incision, the aponeurotic structure, in which the other abdominal muscles end, comes into view, and is easily divided without cutting muscular fiber. Then the fascia transversalis, the subperitoneal fat, and the peritoneum are cut in succession. If pus has formed close against the anterior abdominal wall, these last-mentioned tissues will be found infiltrated with serum, and even thickened so as to look like cheesy tubercle. Otherwise these parts may appear perfectly normal. On opening the peritonaeum the appendix may at once be seen, or adhesions or inflammatory exudations may have so distorted the parts that a careful and difficult search may be required to find the appendix at all. It may be flattened out and glued firmly to the inflamed surface of the caecum by old and recent adhesions, or it may be coiled upon itself and buried out of view in a mass of lymph. The finger is often quicker than the eye to detect the appendix in these conditions, as it is very certain to be found where the greatest thickening, as felt by the finger, exists. More than once I have had to turn the caecum out of the wound and examine carefully the usual region of origin of the appendix before I could identify it. Usually then with the finger or a dull-pointed instrument the adhesions can be broken down or tied off, as may seem required by vascularity. If the appendix has been thus separated, I have usually tied it off with silk or catgut close to the caecum and cut it away, and generally between two ligatures. Careful disinfection of the stump should be made. I have scraped its interior and disinfected with 1-to-1,000 bichloride solution, and then rubbed in iodoform. Once, where it looked dangerous, I tied with silver wire, and then used the fine-pointed cautery to disinfect. If thoroughly cleansed, it seems to be unnecessary to lose time sewing the peritonaeum over the stump, as recommended by Treves. When the appendix has been removed nothing remains to be done but to disinfect the whole neighborhood, insert a drain, and pack the small space with iodoform gauze. The upper half of the wound may perfectly well be tightly closed with stout sutures, which should include the thickness of the whole abdominal wall peritonaeum as well. In some cases I believe it to be good practice to introduce a large drain by a separate opening well above and behind the iliac spine, for in some cases the region of disease may extend especially in that direction. But the question may fairly arise in any case as to whether it is wise to attempt to dissect out the appendix and remove it. If the difficulties of dissection would evidently be very great, I think it is better to open the abscess if there is one, cleanse the cavity, and, leaving the appendix in situ, pack and drain the wound.* The packing I have usually removed on the third day and replaced it with less, and the cavity has rapidly granulated. If, at the time of operation, one introduces sutures throughout the whole length of the wound, leaving the central and lower ones loose, these can subsequently, after one or two dressings, be tied, and the wound thus rapidly narrowed. Over the whole wound, of course, a complete dressing is applied, and good bandaging is better than any binder, to prevent the possibility of extrusion of the gut by either vomiting or intestinal distension. None of my patients have developed a hernia at the site of operation. I have kept them all in bed for four weeks or more. None have had any recurrence of inflammatory action of any kind. A few more words, Mr. President, and I have finished. Are there any contra-indications to this operation in a clear case of appendicitis? I think there are. Very great abdominal distension, which might in a given case probably be relieved by a few hours' treatment, would lead me to delay the operation, for expulsion of the intestine is a very serious obstacle to the proper completion of the operation without risk. Unusual obesity I should regard as a good reason for a more expectant method of treatment. But the most important contra-indication of all is the absence of any one of the necessary safeguards and aids, such as the best assistance, the best light, and the best appliances for performing a perfectly aseptic operation. * Since reading this paper I have carefully observed three other cases. In two the point of pain shown by pressure with one finger was two inches, and in the other an inch and seven eighths from the anterior spine. * In a case operated on prior to this paper, it would have been a dangerous proceeding to remove the deeply seated and strongly adherent appendix. I broke its wall at one point, and then drained through the loinand packed in front. The treatment was completely successful, and the patient is safely convalescent. copyright ©, Columbia-Presbyterian Medical Center [Go to start of Document]