THE INDICATIONS FOR EARLY LAPAROTOMY^ IN APPENDICITIS. WILLIAM W. KEEN, M.D., OF PHILADELPHIA. Reprint i'rom Annals of Surgery, June, 1891. THE INDICATIONS FOR EARLY LAPAROTOMY IN APPENDICITIS.1 WILLIAM W. KEEN, M.D., OF PHILADELPHIA. PROFESSOR OF THE PRINCIPLES OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE. IN this brief paper I shall have no opportunity of entering into a relation of cases, or of alluding to the technique or to other details, but shall immediately pass to the topic as- signed me. I am glad that the Committee have selected the name “Ap- pendicitis” rather than the formerly more common “perityphli- tis,” for there is no doubt that Fitz is quite right in claiming that “every case of so-called perityphlitic abscess must be re- garded as primarily one of perforative appendicitis, unless proved to be the contrary,” and Mcßurney is right in estimat- ing that perityphlitis as compared to appendicitis exists in not more than the proportion of one to one hundred. Not that cases of properly so-called perityphlitis do not exist, but that the form which we are to discuss at the present time, namely, an abscess in the right iliac fossa, as well as many other cases without abscess, almost always arise from appendicitis, and most frequently, perforative appendicitis. Matterstock found perforation in 132 out of 146 autopsies where there was suppuration, Fenwick, 113 out of 125, Weir, 34 out of 100, and Kummel places his percentage at 100. Hence I think the prominence that has been given of late to the appendix rather than to the caecum is amply justified by the facts. URead before the New York State Medical Society, February, 1891. 2 W. IV. KEEN. For clinical purposes five forms of appendicitis may be rec- ognized. First, a mild form of appendicitis without perforation, end- ing usually in resolution without the formation of an abscess. Second, perforative appendicitis, followed by general peri- tonitis. This form appears in two different modes: (a) a se- vere, early and often fulminating peritonitis, and (b), a form which is apparently mild, and, after continuing so for a certain length of time, suddenly bursts out into a disastrous general peritonitis, either from perforation of the appendix or rupture of an abscess which sometimes has not even been recognized. Third, the most common form, in which the appendix is perforated and a local, and, as Mcßurney has happily called it, a “comparatively safe” or “comfortable” abscess forms more or less rapidly, and either is operated on or ruptures exter- nally or into a hollow viscus, and finally ends either in resolu- tion or death, usually within two, three or four weeks. Occa- sionally by the rupture of the abscesss into the general cavity of the peritoneum this form is suddenly transferred to the pre- ceding class. Fourth, a class in which the abscess forms slowly and fol- lows a chronic course, lasting for not only weeks, but even months, and it may be a year, before it either discharges or is operated on. Fifth, recurrent appendicitis in which attack follows attack at longer or shorter intervals, until finally the last attack kills, especially if not operated on, or the patient may, perchance, recover. From the very nature of the topic assigned me “In- dications for Early Laparotomy,” the last two forms are ex- cluded from this discussion except incidentally. First, the mild form of appendicitis. That this is frequent is proved abundantly by the statistics of Tofft, Hektoen and Fitz; so frequent, indeed, that we must assume that nearly one- third of all adults have had one or more attacks. Most of them have been overlooked, perhaps, for in most cases that I have seen the attack has been deemed by the patient to be one of simple indigestion, or of colic, or of some other similar and common intestinal disorder. This very frequency has been urged by some as a reason for frequent operative interference. EARLY LAPAROTOMY IN APPENDICITIS. 3 To my mind it argues precisely the reverse. If one-third of all post-mortems of adults give evidences of appendicitis re- covered from without abscess and without operation, it is to my mind the strongest reason why we should, on general prin- ciples, deem that an operation in this class of cases is by no means often to be done. But it is especially to be observed that these attacks which have been recovered from by medical means alone have been of a mild form, and have usually been unrecognized as appendicitis except on the post-mortem ta- ble. We may, therefore, dismiss this class of cases as not re- quiring any operation, save in exceptional cases. Second. Precisely the contrary may be said of the next class, of which every case demands instant laparotomy; namely, those cases of perforative appendicitis which are fol- lowed by general peritonitis, often in such a fulminating form that life is destroyed, even in the course of twelve to twenty- four hours. Such a form as this is usually easily diagnosti- cated, and the indications are so clear that they cannot be mistaken by any well-informed physician or surgeon. Unfor- tunately in too many of the cases the need for instant laparot- omy is so urgent that it is impossible for the physician to call the surgeon in consultation, and for the latter to make the necessary preparations as to assistants, dressings, etc., before the patient is almost past hope. No cases in surgery, saving, perhaps, haemorrhage from large wounded vessels, require more prompt interference, and even then with comparatively little hope of rescuing the patient. The indications for instant laparotomy are; Brief symptoms of recent appendicitis, or of one or more recurrent attacks, followed by sudden excruciat- ing pain all over the abdomen, but most severe in the right iliac fossa, with the familiar picture of general peritonitis and impending collapse. Sometimes, however, instead of this acute course from prim- ary perforation the case will apparently first belong to the cat- egory of milder cases, requiring no operation. The patient is seemingly doing well, has but slight fever, moderate pain and tenderness, and but little tumefaction. He may even be improving, and the fears of the physician may have been lulled by the apparent security which makes the awakening the more 4 IV. IV. KEEN. startling. In spite of the deceptive mildness of the attack ul- ceration has gone on insidiously till perforation, or in many cases gangrene of the appendix, has occurred.2 Some, if not many, of these cases must go on, unrecognized even by the most careful observers, but I earnestly believe that operation is rightly undertaken when there is persistent pain and tenderness, especially at Mcßurney’s point, with even slightly increased resistance without any tumor, with possibly a slight oedema and a moderate fever. An exploratory opera- tion in careful hands with modern antiseptic methods has comparatively little risk and I believe this risk will result in fewer deaths by far than will the expectant delay which has been generally heretofore the rule. Show me a case operated on in which the operation was a mistake and for every one, ten can be shown in which the Fabian policy of waiting for the signs of tumor or of peritonitis was fatal. Even if the oper- ation was unnecessary and, therefore, a mistake it will rarely cost a life, but the opposite mistake is nearly always fatal. Most commonly, however, I believe these cases belong at first to the next class, in which an abscess, not perhaps of large size, has really formed, and, not having been recognized and operated upon, it has suddenly burst into the peritoneal cavity. In many instances again it is impossible to distinguish between those cases which will run a continuously mild course and ter- minate in resolution and the apparently mild cases which run a nearly parallel course, but which are accompanied by abscess and finally burst into such fatal fierceness. But I believe it is not impossible, by minute and careful ob- servation of the points to which attention is called in the next class, to be able in general to determine whether an abscess has formed, especially by the most minute and delicate palpa- tion, sometimes by rectal and vaginal examination ; often by the possible overlying oedema; and generally by the tender- ness at Mcßurney’s point, in addition to the general constitu- tional symptoms. The general constitutional symptoms, it 2I believe there has been no bacteriological examination of the contents of the unruptured but catarrhal or ulcerated appendix. It is greatly to be desired that such should be made and the nature of the contained micro-organisms be ascer- tained. 5 EARLY LAPAROTOMY IN APPENDICII IS. can scarcely be too strongly insisted on, are far inferior to the local signs in forming an accurate diagnosis. Even the tem- perature, so commonly a reliable guide, may be most deceptive, for the lesion is distinctly local in its chief activity and the body heat is usually only moderately elevated and may subside while the local process is absolutely progressing toward a most dangerous or a fatal issue.3 The only general symptom of especial value is severe pain arising, as has been pointed out by Stimson, not as an initial symptom, when it is often se- vere, even in otherwise mild cases, but arising more or less suddenly in the course of the attack. This very pain itself may be more justly called a local than a general symptom. I would lay it down as a rule, therefore, that even in mild cases, and in cases that are apparently convalescing, if the in- dications point even slightly toward pus an early operation should be done. If pus is present the propriety of an opera- tion, I am sure, will be denied by no one, and if it is absent a simple exploratory operation with all the precautions of mod- ern antiseptic surgery is so far from being dangerous that no patient should be allowed to run the risk of a probable or pos- sible rupture and general peritonitis. An exploratory opera- tion “carries with it less danger than the disease.” The same challenge just made above may be confidently repeated. That such apparently mild disease may be seemingly pro- gressing toward recovery, and yet imperatively demand an operation, is well seen in a case reported by me in the Medical and Surgical Reporter, so long ago as February 6, 1886, page 165, which was as usual regarded by the patient at first as an ordinary colic. When I saw him on the sixth day his temper- ature, which had been 102.40, had fallen on the fourth day, and on the sixth day was only 99.40. The pulse was only 88, legs extended, belly not markedly tender. The pain had almost disappeared, so that he was comfortable, could turn in bed and 3Since this paper was read I have operated in the Jefferson College Clinic on a young man, ninety-two hours after the beginning of the attack with moving temper- ature of only 990, and yet an inch of the appendix was tailing into gangrene around a large faecal concretion, and a half pint of fetid serum and flakes of fibrinous exu- date were discharged from the right iliac fossa. He is recovering without a bad symptom. 6 IV. IV. KEEN. use his right leg without suffering. No fluctuation could be detected and deep pressure produced but little pain, but there was considerable oedema, and an operation revealed an ab- scess containing nearly a pint of fetid pus. Moreover, we must remember that peritonitis and death may occur even without either gangrene, perforation or a local abscess. The third class of cases, however, is that which most frequent- ly comes under the eye of the surgeon. They occupy a middle place between the mild form, so often overlooked, and the acute form of general peritonitis. Even in this class the symptoms are not seldom latent and may escape notice un- less the physician is on the alert and has been forewarned of the possibility of appendicitis, either by such a discussion as the present one, or by his reading, or it may be by sad expe- rience. Usually there will be more or less pain, commonly quite se- vere. This pain is often not at first located in the right iliac fossa, but may be over the whole abdomen, in the epigastrium, the hypogastrium or even the left iliac fossa. In time, how- ever, though it may persist elsewhere it generally becomes most severe in the right iliac fossa. Dr. Mcßurney has done a good service in pointing out that tenderness to pressure is es- pecially marked at a point “an inch and a half to two inches from the anterior superior spine on a straight line toward the umbilicus,” and it is best determined by pressure with the tip of one finger. Sometimes the tender point is a little lower than the line. It is often best indicated by the patient himself. With this pain will usually go nausea, vomiting (not stercoraceous) and constipation. The fever will be marked but rather moderate, rarely over 103° and more com- monly in the neighborhood of ioi° or 102°. Dullness on su- perficial percussion not seldom may be absent by reason of in- terposing coils of intestine. Deep percussion may, however, show diminished resonance and even dullness; and a delicate touch may discover increased resistance, and this physical sign as well as the dullness may be marked. Both of these signs are generally best marked under ether. Even when a large abscess is present I have never been able distinctly to discover fluctuation and I place no reliance whatever on the absence of EARLY LAPAROTOMY IN APPENDICITIS. 7 this sign. A sign which has been too much neglected I think is the oedema which is so commonly seen overlying a deep ab- scess. If the right iliac fossa be doughy with oedema I believe it is almost always a reliable sign of suppuration.4 Moreover, pus will be present much earlier than was formerly supposed to be probable and, therefore, an operation should be done much earlier than we formerly believed to be wise. Willard Parker, in 1867, was the first to compel the profession to hear him, and recom- mended that an operation should be done between the fifth and twelfth day. With increasing experience and, especially in the light of better results from earlier operations, last year Fitz expressed the view that the third day was not too early. When we remember that these cases arise from abscess, pro- duced either by extensive inflammation of the appendix, or far more commonly from gangrene or from perforation ; that such perforation will instantly light up a sharp local peritonitis limited by the agglutination of the neighboring coils of in- testine, and that common experience shows that even in con- nective tissue, as, for instance, from a felon or a boil, pus readily forms in 48 to 72 hours, we must expect that in the per- itoneal cavity pus will form at least as early. This presump- tion has been turned to certainty by a number of recently re- ported cases. The limit set by Fitz then does not seem un- reasonable. Even as much as three pints of pus have been found by the fifth day. This large quantity would require cer- tainly two to three days for its accumulation after suppuration had begun. To establish the existence of pus I was formerly inclined to use the hypodermatic syringe, but a larger experience has con- vinced me that an exploratory operation is much more certain and also much less dangerous than the needle. The disease it must be remembered is apt to prove fatal at an early date. In the 176 cases collected by Fitz 68% died in the first 8 days and two-thirds of these between the fourth and eighth days. 4Several times I have noticed this oedema in the layers of the connective tissue between the muscles, even if absent under the skin. Its existance is of great value as a positive indication of pus at a lower level. 8 W. W. KEEN. I should, therefore, formulate a general rule that by the sec- ond, certainly by the third day, and a fortiori later, the opera- tion should be done if the following indications are present: First, if there is abdominal pain, most marked in the right iliac fossa and especially with tenderness at Mcßurney’s point, attended possibly with nausea and vomiting. Secondly, if there is rigidity of the right abdominal wall. Thirdly, if there is fe- ver up to ioo°, ioi° or 102°, which does not yield to medical treatment. Fourthly, if by minute and careful palpation tume- faction and increased resistance can be discovered, with possi- ble dulness and rarely fluctuation; and fifthly, if there is oedema of the abdominal wall. Pus will generally be found, but it is possible that there may be none. If pus is present the abscess cavity is to be evacu- ated and washed out with great care, lest its frail wall be broken down and general peritonitis ensue. If there be no pus the appendix should be sought and if, as will I believe almost uniformly be the case, it is swollen, thickened, distended the seat of a concretion or otherwise abnormal, even without perforation, it should be tied and cut off and the stump either be simply disinfected, or, as I prefer, inverted and covered by a few Lembert stitches through the outer layers of caecum. The brilliant results which have been reported by Senn, Tre- ves, Mcßurney, Stimson, Bernardy, Baldy and others, in cases in which no pus was present but the appendix was perilously dis- eased, have abundantly shown that such an appendix is a men- ace to life compared with which the dangers of an aseptic operation are nothing. Moreover, I should be decidedly in fa- vor of an operation even if there were present only iliac pain, tenderness at Mcßurney’s point, rigidity of the abdominal wall, moderate fever and increased resistance without tumefac- tion and d Iness, nausea and vomiting. The unusually large personal experience of Fitz shows that five-eighths of all cases and one-fourth of the cases which had been treated medically alone should have been operated on. With so large an expe- rience from so careful and accomplished an observer, it is a crime for us to go on allowing case after case to die that ought to have been relieved by surgical interference. I cannot close this paper without calling special attention to EARLY LAPAROTOMY IN APPENDICITIS. 9 what I believe is a most important point in connection with ap- pendicitis, and it is especially appropriate to so large and influ- ential a body as this, composed both of physicians and sur- geons from all parts of the Empire State. The warning has already been sounded but it cannot be too strongly insisted upon that in every case of suspected or proved appendicitis or perityphlitis a surgeon should be called in consultation at the oiitset. If called later when an emergency has arisen and there is need for surgical interference, if the need be absolute, it is of course evident that the surgeon will immediately oper- ate. But in the great majority of cases he will necessarily be tempted to be cautious and conservative, desiring greater fa- miliarity with the details of the case, and to postpone any op- erative interference, at least for one or two days, too often a fatal delay. This is neither fair to the surgeon nor to the pa- tient. The need for familiarity with the case on the part of the surgeon, and the right of the patient to have the very best time selected for the operation, demand that the surgeon should be called in consultation early in the case, that he should be familiar with it from repeated visits, and should be ready instantly to seize the favorable moment for operation. It must not be thought that any conscientious man, because he is called in as a surgeon, will wish immediately to operate ; but it is his right, and it is also the right of the patient, that the surgeon, in order to be able to determine this momentous question wisely, should have the entire course of the disease at his fingers’ ends by frequent personal observation, rather than by information filtered all at one time through the mind of the physician. Confessedly many cases are doubtful and require the most careful weighing of the evidence for and against operative procedure. The surgeon who has attended the case in consul- tation with the physician from the outset, and the physician who all along has had the benefit of the surgical advice of a colleague, will both be far better fitted to cope with any sud- den emergency and both will be far more likely to select the wisest time for the operation. The very first “indication for early laparotomy in appendicitis,” therefore, is to call in the surgeon early.