THIS is a report of 421 cases operated on by a highly specialized technic. These were all personal operations by the author. They included all types of cases as they came. They included all agents. They were operated upon in four different hospitals in the metropolitan area. This shows that they were not selected cases. They were consecutive.
The pathologic diagnosis was verified in every cases and ranged all the way from simple catarrhal appendicitis to the acute gangrenous type.
There were four deaths in this series.
(1) Diagnosis of acute gangrenous appendicitis with rupture and general peritonitis, died on the operating rupture and general peritonitis, died on the operating table, evidently moribund and hardly a fair case by which to judge the value of the operation. Also a case that cannot be fairly attributed to the operation.
(2) Acute gangrenous ruptured appendix, with a concretion.
(3) Subacute appendicitis,died suddenly from an embolism nearly two months after the operation. Also a case that cannot be fairly attributed to the operation.
(4) This case was sick for a month before he was operated upon. having been treated for typhoid fever. He died eight days after the operation from a general peritonitis.
The complete mortality rate is about 1 per cent. If the two cases which were hardly fair to include as a mortality were removed, the rate would be cut in half -5 per cent.
There are three reasons for this low death rate. The first is the fact most of the cases were private ones and had been carefully diagnosed early by the medical practitioner. Second, the technic of the operation, which will be described later. Third, the early use of hypodermic cascara and pituitary extract preventing dilated stomach, and the right lateral prone position levering localization of the infection in the right lower quadrant.
The operative technic, which is shown in the moving picture, is a modification of the McBurney. The original McBurney incision was made one-third of the distance from the distance of the anterior superior spine to the umbilicus. The skin is then cut and the muscles split in the direction of the fibers, the peritoneum being lifted and cut. The center of this incision usually found itself located at the junction of the ileum with the caecum a little to the ileal side, thus invading the general peritoneal cavity.
When you consider that nearly 90 per cent of this series of case showed that Wakeleys report was correct, ie., that in about 90 of cases the appendix is located retrocaecal or retrocolic, the right rectus incision and even this original McBurney incision bring one to the median side of the proper operative field.
The modified incision is located a fingers breadth medial to the anterior superior spine. The average length is approximately one to one and one-half inches. The muscles are cut in the direction of the fibers and lifted by hemostats and not retractors. The peritoneum drops well down but is adherent at its outer side to the lateral wall. By raising the abdominal wall with a hemostat the outer fold of the peritoneum is brought into position. It is usually covered with abdominal fat and sometimes a little difficult to distinguish. The fat must be wiped off carefully with forceps to make sure one has the peritoneum.
The avenue of approach at this spot lies external to and behind the caecum. Sometimes the appendix is so far to the outer side that the tip is quite easily visible, but as a rule the examining finger should be passed into the abdomen and the caecum and appendix located carefully, not breaking up any adhesions. The eye in the end of the finger becomes so educated that the pathology is quite apparent. Possessing the long type of index finger, one readily can palpate the right ovary and tube.
If the pathology is serious, common sense dictates lengthening the incision upwards or downwards, according to desire. The approach to pathology is much safer from the lateral aspect. The adherent appendix can much better be removed from behind and to the outer side of the caecum than towards the median line.
The appendix is removed in the ordinary clamp, ligature, carbolic method, the approved method of choice in a survey made of practically all of the hospitals in the United States several years ago, under the auspices of the Archives of Surgery.
From the point of anesthesia alone, the location of this incision is of interest. Our anesthetists tell us that or patients require lighter anesthesia with less resultant shock; our nurses tell us that there is less gas pain, a better morale, and a quicker recovery.
The average time of bed rest in these cases, in men, is about two days; in women,from three to seven days.
The incidence of hernia is practically nil except in the cases where there was, necessarily, drainage. The one month, six months, and a year, follow-up examinations show practically no untoward results.
The contra-indications for this type of operation are: (a) the existence of any other more serious abdominal pathology, where the appendix is simply an incidental part of the trouble; (2) the lack of careful diagnosis; (3) a lack of technical skill and anatomic awareness (the technic of this operation requires thoughtful execution step by step.