APPENDICITIS
as
a
of
cause
intestinal
OBSTRUCTION.1 BY
Richard Warren, M.D., Surgeon
to
the
M.Ch.
Oxon., F.R.C.S.,
Weston-super-Mare Hospital.
T>
v
in
things
behaviour
surgery
are
remarkable
more
of
than
the
the
plastic lymph poured by peritoneum to irritation. beneficial Though usually by losing perforations, or by walling off inflamed areas and so Preventing widespread contamination, or by securing our Crude surgical suturing of hollow viscera, yet occasionally results are disastrous, as the lymph, even before as a
out
response
rga.nisation ernbranes
P^?duce
has
which
the
obstruct
unfortunate
Intestinal
obstruction
appendicitis* other huand it ?
the
intestine of
as a
sequel
to
or
or
and
intestinal
concomitant
a
but
common,
?
on
the
?
not
extremely
34 times in 1,011 I have notes.
addition cases
kink
is fortunatelv not
is
furred ^hich
or
complication
obstruction. ^
may form bands
properly occurred,
cases
rare.
of
The
operation
there occurred in
a
certain
complication appendicitis
for
proportion
of
...
n a
condition of loculated fibrino-purulent peritonitis C1ated with a certain amount of obstruction in which
?bst
resillt
Action, n
was
and these
1 I
perhaps cases
began to look C1ated the frequency
*ead Xov tmb" before
a
Meeting
12th, i924.
more
have
a
from
peritonitis than high mortality.
very up the notes of cases I never and importance of appendicitis
of the Bristol
Medico-Chirurgical
Society
MR.
24 as
a
RICHARD WARREN
of intestinal
cause
180
Of
obstruction.
cases
of
obstruction upon which I have operated 68 were due to stricture (usually malignant), 54 were bands and kinks, were
40 rest
intussusception volvulus 11,
were
obstruction
definitely experience by
were
But in several of the bands
it is
5
that
probably
no
common more
Clinically,
more
of
months
the by bands and
of obstruction
not discovered
obstruction
common
than three
operation,
at
certain number of these
cases
cause
appendicitis, usually
probable results of appendicitis. a
n?
occurred either
cases
attack of
cases
was
far the most
It is
during or shortly after days or weeks, the longest cause
groups, the and gallstone
big
appendicitis, which
due to
for these
figures suggest, an
later.
hernia
internal
makes it in my of this form of obstruction. than these
the
are
Now of the group of bands and kinks
2.
less than 34
these
;
due
to
were
also the
appendices
fall into two groups : (1) Primary, and (2) Post-operatecIn the former group there were 13 cases, in the latter 21. 1.
is
Primary Obstruction.?As and
recent
obstruction,
acute,
but
the
possibly
something the following is A
than a
rule
fever and
right
some
iliac fossa,
obstruction.
simple fairly typical example a
the whole
symptoms suggesting
with
tenderness and resistance in the more
a
aff'lir acute
localise^
suggest111^ type
Of this
:?
female, aged 70, ill twenty-four hours with
rcllC'j^e
distension and constipation. g temperature was subnormal, the pulse normal and therc ^^ tenderness in the right iliac fossa. Operation was immediately and showed an acutely inflamed appendix adnc ^ ? to and kinking the lower ileum with marked distension o gut above and emptiness of that below. Removal u t appendix from its lymph bed automatically released ^je and the patient made a good recovery. It was reinar ^ what a small amount of recent lymph, only a few hoi days old, could produce intestinal obstruction.
vomiting,
abdominal
^
perj(eI1t
^
APPENDICITIS
as a cause
of intestinal obstruction.
25
A similar clinical picture may be produced by obstruction ?f the lower colon with distension of the caecum, which is
becoming ulcerated aged
and
beginning
to
leak, and in
middle-
a
the distinction between these two
or
elderly patient is almost impossible.
c?nditions A less A
common
type
is the
following
:?
?
boy, aged 8,
suffered with belly-ache and occasional for a month. His appetite was bad and he sweated night. For two days before I saw him his bowels were t open and the vomiting was more urgent. When seen he a typical abdominal facies, marked distension of the men with visible peristalsis of small gut. The temperature as l00? F. and the pulse 100.
a?mi.ting ,
^
,
,
Operation.?Laparotomy found
done immediately, and it was three feet of the ileum immediately caecum were kinked and matted by adhesions, the above was much distended, and the caecum and colon An acutely inflamed appendix was removed from of the matted ileum and the adhesions were broken ^ ^ was uncertain whether the intestinal contents Wn 11 ^ass through such a length of injured intestine, a lateral am 10S^S Was niacic between the ileum above the kinked Part dn partly because of the difficulty of diagnosis, ^
n0t
atonic
distinguish staSes ileu^ early generalisedearly from by peritonitis 1;>and, partly longer patient an^Cent has already vitality operation, i.e. died, group pe^ressedCCnt'' wbich intestinal b
to
^1C
Casy
0r
obstruction
has been ill
because the
had
^
Of
cases
in this
is
that
more
about 30
7
is the average
oh
of
21
so
one
mortality
for
in my
experience. pUcti?n 0s^?Perative obstruction
the nrirr.
ternary operation
with
usually
arises within
paroxysmal
a
week
abdominal pain,
26
MR.
vomiting which a
subnormal
RICHARD
WARREN
becomes green and later brown and
temperature.
when it occurs, but is
possibly
The latter is very suggestive to be masked by the irregular
likely accompanying peritonitis.
commonly the obstruction develops later, weeks or months after an attack of appendicitis, with well-developed fibrous adhesions and bands arising from the former plastic lymph.. No doubt fever of
some
an
of the bands which
obstruction
such,
and is
are
not
of
divides in
one
appendical origin,
therefore
following example definitely appendicular an
Less
of in
included
a
late
case
origin
in
but
a
of acute
case
as
not
this
proven The series.
of intestinal obstruction
:?
A male, aged 42, was operated on for suppurating appendicitis three months ago, the appendix was removed and the abscess drained. Attacks of abdominal pain with distension and vomiting followed. These were relieved by enemata, but tne attacks were recurring and becoming worse. On examination there was a well-marked incisional hernia* a tense and distended abdomen, a pulse of 100 and an anxious
expression. Operation was undertaken at once. Laparotomy was done through the previous scar in y1 Y right iliac fossa. The lowest foot of the ileum was bad kinked up by adhesions, the gut above being red and distende the colon empty and contracted. After freeing the adheSl? ,
>
the gut was raw over an extensive area, and it seemed proba that kinking might recur, so an ileo-cfecostomy was done short-circuit the kinked part of the ileum, the ventral was repaired in layers with overlapping. He n recovery. Later he developed acute cholecystitis.
her^ but u
Diagnosis.?Complete diagnosis may not be easy, ^ ^ less important in the primary cases, since in these Cllfe usually pretty clear that the condition is one 01 ^ abdomen," with signs pointing partly to obstruction ^ partly to some inflammatory affection and that opef< t is is urgently indicated. The only noteworthy point ^ open the abdomen by the paramedian incision rather r
"
o
'
j
APPENDICITIS AS A CAUSE OF INTESTINAL OBSTRUCTION.
in
the
have
27
right iliac fossa, so as to give plenty of room if adhesions
to be dealt with or an anastomosis
performed.
In the
post-operative type diagnosis may be difficult extremely important, as on the one hand one wants
and is
to relieve
a
true mechanical obstruction as soon
by operation, handle
really
the other
on
possible
as
does not want to further
one
and abuse inflamed intestine when the condition is
one
of
peritonitis
and ileus.
A sudden attack of
paroxysmal pain with rising pulse falling temperature, occurring in a patient who has been going on smoothly after the first operation, is fairly
and
suggestive vomit
of
when
obstruction
becoming
brown, with
cases there should be
a
delay
no
associated
with
bilious
soft abdomen, and in such in
opening
But where the condition is a mixture suppurative peritonitis diagnosis and
the abdomen.
of obstruction with treatment
are
alike
difficult. I he A
following is
girl, aged
a
good example of this type
15, with
a
history
of two
of
case :?
days.
At the first
patient
did well for
?Peration a gangrenous appendix was removed through a andiron incision, and as it was surrounded by foul pus the M?und
was
drained for two
days.
The
s?me days, then began to have irregular fever and per rectum ^gns of a pelvic collection. This was opened by a medium
day and proved to be of some size. large tube. Irregular pyrexia persisted, developed. The condition was not
on the thirteenth Incision was drained with a
ancf
faecal
a
fistula but there was 110 evidence of loculated pus. Wenty days later, i.e. thirty-three days from the first operation e patient had severe abdominal pain and vomited eight nies in the night, the temperature became subnormal and 10 markedly abdominal. third operation was done, a higher mid-line incision being an^ were broken down and a very small lo cu 1 ated many adhesions abscess found and drained. It did not appear to be Vory satisfactory operation, but the patient slowly recovered playing hockey three or four months afterwards. Se.emed to be mainly a case of fibrino-purulent peritonitis \vl Uc 1 1 developed obstruction.
satisfactory, /ace.
'
'
Tjv.as incidentally ?
28
MR.
.
RICHARD WARREN
Treatment.?In the
to several of the methods
is
fairly simple dividing
which
can
the
bands of recent
or
be done with the
onset do the adhesions
of
question
anastomosis.
finger; only require cutting.
further
When the
in the
types
More
such
treatment,
gut
already referred
In most instances it
possible. band
a
I have
quoted
cases
as
lymph, of later
important
is
drainage
or
above the obstruction is very
distended and the contents do not
readily
flow
past
the
of obstruction after its division the gut should be tapped with a medium trocar and gas and liquid faeces let
seat
puncture closed with purse-string suture. If the condition of the gut still appears doubtful a temporary fcecal fistula should be made, and I have found an ileostomy
out and the
of the
self-closing type quite satisfactory, using
catheter
as a
Where
a
a
No.
i2
drain.
large
amount of small
gut
is matted, and it is
rapidly become obstructed again, a short circuit should be done, usually an ileo-caxostomy to which a valvular caxostomy may with advantage be added in the more acute cases, as suggested by Handley some 1 anl years ago for the condition he calls ileus duplex. doubtful if it will not
doubtful of the
occurrence
of this condition
as
lie
describes
sigmoid at the same timeThe ileus is, however, certainly duplicated in many cases in another sense, I mean that there is peritonitic as well it,
viz.
a
block of the ileum and
ileo-caccostcmy with a caicostomy is very similar to that of a simple ileostomy* and possibly better where the patient will stand this further as
obstructive ileus.
The effect of
an
manipulation. same
subject
has
and
an
I have very similar to those his conclusions are very similar^ to miru>
in which he mentions
described,
the
interesting paper on appeared by Rayncr of Manchester,
Since I wrote the above
1
cases
II.M.J., i.. iy2.j,
p.
855.
APPENDICITIS AS A CAUSE OF INTESTINAL OBSTRUCTION.
29
except that in the treatment of post-operative obstruction he advises the use of stomach tube and morphia for one
proceeding to operation and quotes a successful case. Personally I think that twelve hours is long enough to persist in such cases unless marked improvement is noted, and should think that ileus relieved by such treatment is more probably peritonitic than true obstruction. Another paper bearing on this subject was from America. or
two
days
before
I have lost the reference.
drainage
in the
right
The author of this found that tube
iliac fossa
followed far less
was
operative obstruction than where the drain
mid-line. ment.
I have not
by post-
was
in
the
data to criticise this state-
enough
usually employed the gridiron incision and the post-operative cases have been drained, usually with the drain two days in the abdomen and a few more days ln the abdominal wall, i.e. all the post-operative cases followed a fairly severe peritoneal infection whether localised I have
?r not.
DISCUSSION.
Hie President thanked Mr. Warren for his dnd valuable
*^s
a
contribution,
physician
he would be
on
which discussion
glad
interesting
was
invited.
to hear whether Mr. Warren
c?uld recommend any measures that tended to prevent these post-operative obstructions. He recalled the late Mr.
Poole Lansdown's advocacy of practicable after operation
abdominal massage
??n as
^lexv to
preventing
the
occurrence
for
appendicitis
agnose from
Peristalsis
was
all other
^henfoiled, d
peritonitis
and from
the most conclusive means
of
obtaining
he had several times
with
a
of adhesions.
Mr. Rendle Shout remarked that these cases struction following appendicitis were often
0
as
ileus,
sign. an
seen
of intestinal difficult
to
and that visible In
cases
of
ileus,
action of the bowels lives saved
by
the
MR.
30 "
attack
triple
"
enema, and
oil,
ileostomy Mr.
dose of two
a
a
turpentine hypodermic of a
course, this will not avail
Of
if there
Under those circumstances
authentic obstruction.
an
giving
then four or five hours later
whilst it is still in the bowel
extract.
pituitary is
this consists of
;
minims of croton
RICHARD WARREN
under novocain anesthesia may be safer. pointed out that these
Ferrier Walters
operative diagnose,
obstructive adhesions and that he
were not
regarded
vomit
post-
seldom difficult to
becoming feculent,
48 to 72 hours free from this symptom, He preferred the as suggestive of inflammatory obstruction. pelvic drain, and had given up draining from the wound. after
It
an
was
interval of
important
to take care that
allowed to intervene between the bladder.
no
coil of intestine was
drainage
tube and the
He would like to hear from Mr. Warren how often
Sampson Handley's ileus duplex. incision, invariably used Battle's incision, cn females, where a doubt existed as to diagnosis, since this incision lends itself to such other operations as might -J prove necessary in cases in which the diagnosis proved incorrect. He used the gridiron, however, in men and children, as there is little liability to subsequent hernia, and one could get the patient up within a week. Mr. Chitty, referring to the suggestion that obstruction he had met with
cases
was more
than
of
he
As to the
often
when
Mc
that obstruction
seen
when Battle's incision
Burney's operation was
more
common
necessary, and he considered appendix from the inner side, as in more
often followed
by
when that
was
been
was
was
empl?}c^
performed, said pelvic drainage the
approaching
had Battle's incision, obstruction in his own cases a
1
adopted the gridiron incision, ana appendix more laterally. Consequently
than when he had
cO *
approaching the preferred the latter incision unless the presence of pdvlC un es suppuration was suggested by rectal examination, or
APPENDICITIS as a cause of intestinal obstruction.
some doubt
exploratory
as
to the
diagnosis
renders
a
more
31
extensive
incision advisable.
Mr. Tasker said that he had used Battle's incision in ?ver two
appendicectomies, and had only enpost-operative obstruction. He had c?me to the conclusion that if a drainage tube had to be Used, post-operative hernia more often followed McBurney's countered
hundred
two cases of
lncision than if Battle's incision was used. Mr. Lacy Firth stated that after using the gridiron lncision for many years he was led to adopt Battle's incision, which had the advantages in his opinion of giving a better exPosure
and of being easily extended for further investigal0n when the diagnosis was doubtful. He had not met
Wlth the
cases
which Mr. e had met
Peritonitis
of mechanical obstruction in acute
Warren had described.
appendicitis
The obstruction
with had been considered to be due to and treated
as
cases
spreading
such.
Mr. Richard Warren, in reply
an3 method adopted
to
points
raised
during discussion by various speakers, said that he believed it Was difficult to attribute the prevention of adhesions to e
to that end, and he doubted whether
massage of the abdomen avails or makes a material difference,
glii
^
lQugh early movements bed might be
of the
patient
while still confined
helpful. Mr. Short had referred to visible after operation as a valuable diagnostic Peristalsis but he had found visible peristalsis, at any rate in Cases, was somewhat late in appearing, and if present ^ould have no hesitation in opening up the abdomen ^ ?nce- The triple attack was too prolonged in action an aCU^e case requires quick operation, but for th ^ss acute the method might prove of value, though a decided objection to employing croton oil. Mr. Said he had not encountered ileus duplex, and he had cited Sampson Handley in this connection, soon
^CUte
"
th^011
"
MR.
32 he
did
seems
not
agree with
him.
have worked well.
to
tube in the
caecum one
faeces from the ileum inflammation of followed
WILFRID ADAMS
a
appendix.
In
obtained
through
retro-ccnecal
by adhesions
Nevertheless,
the
the
method
ileo-caecostomy with the direct rapid drainage of He
caecum.
appendix
than that of the
is
more
agreed that be
apt to usually located
more
as
a
of
cause
intestinal
OBSTRUCTION.1 BY
Richard Warren, M.D., Surgeon
to
the
M.Ch.
Oxon., F.R.C.S.,
Weston-super-Mare Hospital.
T>
v
in
things
behaviour
surgery
are
remarkable
more
of
than
the
the
plastic lymph poured by peritoneum to irritation. beneficial Though usually by losing perforations, or by walling off inflamed areas and so Preventing widespread contamination, or by securing our Crude surgical suturing of hollow viscera, yet occasionally results are disastrous, as the lymph, even before as a
out
response
rga.nisation ernbranes
P^?duce
has
which
the
obstruct
unfortunate
Intestinal
obstruction
appendicitis* other huand it ?
the
intestine of
as a
sequel
to
or
or
and
intestinal
concomitant
a
but
common,
?
on
the
?
not
extremely
34 times in 1,011 I have notes.
addition cases
kink
is fortunatelv not
is
furred ^hich
or
complication
obstruction. ^
may form bands
properly occurred,
cases
rare.
of
The
operation
there occurred in
a
certain
complication appendicitis
for
proportion
of
...
n a
condition of loculated fibrino-purulent peritonitis C1ated with a certain amount of obstruction in which
?bst
resillt
Action, n
was
and these
1 I
perhaps cases
began to look C1ated the frequency
*ead Xov tmb" before
a
Meeting
12th, i924.
more
have
a
from
peritonitis than high mortality.
very up the notes of cases I never and importance of appendicitis
of the Bristol
Medico-Chirurgical
Society
MR.
24 as
a
RICHARD WARREN
of intestinal
cause
180
Of
obstruction.
cases
of
obstruction upon which I have operated 68 were due to stricture (usually malignant), 54 were bands and kinks, were
40 rest
intussusception volvulus 11,
were
obstruction
definitely experience by
were
But in several of the bands
it is
5
that
probably
no
common more
Clinically,
more
of
months
the by bands and
of obstruction
not discovered
obstruction
common
than three
operation,
at
certain number of these
cases
cause
appendicitis, usually
probable results of appendicitis. a
n?
occurred either
cases
attack of
cases
was
far the most
It is
during or shortly after days or weeks, the longest cause
groups, the and gallstone
big
appendicitis, which
due to
for these
figures suggest, an
later.
hernia
internal
makes it in my of this form of obstruction. than these
the
are
Now of the group of bands and kinks
2.
less than 34
these
;
due
to
were
also the
appendices
fall into two groups : (1) Primary, and (2) Post-operatecIn the former group there were 13 cases, in the latter 21. 1.
is
Primary Obstruction.?As and
recent
obstruction,
acute,
but
the
possibly
something the following is A
than a
rule
fever and
right
some
iliac fossa,
obstruction.
simple fairly typical example a
the whole
symptoms suggesting
with
tenderness and resistance in the more
a
aff'lir acute
localise^
suggest111^ type
Of this
:?
female, aged 70, ill twenty-four hours with
rcllC'j^e
distension and constipation. g temperature was subnormal, the pulse normal and therc ^^ tenderness in the right iliac fossa. Operation was immediately and showed an acutely inflamed appendix adnc ^ ? to and kinking the lower ileum with marked distension o gut above and emptiness of that below. Removal u t appendix from its lymph bed automatically released ^je and the patient made a good recovery. It was reinar ^ what a small amount of recent lymph, only a few hoi days old, could produce intestinal obstruction.
vomiting,
abdominal
^
perj(eI1t
^
APPENDICITIS
as a cause
of intestinal obstruction.
25
A similar clinical picture may be produced by obstruction ?f the lower colon with distension of the caecum, which is
becoming ulcerated aged
and
beginning
to
leak, and in
middle-
a
the distinction between these two
or
elderly patient is almost impossible.
c?nditions A less A
common
type
is the
following
:?
?
boy, aged 8,
suffered with belly-ache and occasional for a month. His appetite was bad and he sweated night. For two days before I saw him his bowels were t open and the vomiting was more urgent. When seen he a typical abdominal facies, marked distension of the men with visible peristalsis of small gut. The temperature as l00? F. and the pulse 100.
a?mi.ting ,
^
,
,
Operation.?Laparotomy found
done immediately, and it was three feet of the ileum immediately caecum were kinked and matted by adhesions, the above was much distended, and the caecum and colon An acutely inflamed appendix was removed from of the matted ileum and the adhesions were broken ^ ^ was uncertain whether the intestinal contents Wn 11 ^ass through such a length of injured intestine, a lateral am 10S^S Was niacic between the ileum above the kinked Part dn partly because of the difficulty of diagnosis, ^
n0t
atonic
distinguish staSes ileu^ early generalisedearly from by peritonitis 1;>and, partly longer patient an^Cent has already vitality operation, i.e. died, group pe^ressedCCnt'' wbich intestinal b
to
^1C
Casy
0r
obstruction
has been ill
because the
had
^
Of
cases
in this
is
that
more
about 30
7
is the average
oh
of
21
so
one
mortality
for
in my
experience. pUcti?n 0s^?Perative obstruction
the nrirr.
ternary operation
with
usually
arises within
paroxysmal
a
week
abdominal pain,
26
MR.
vomiting which a
subnormal
RICHARD
WARREN
becomes green and later brown and
temperature.
when it occurs, but is
possibly
The latter is very suggestive to be masked by the irregular
likely accompanying peritonitis.
commonly the obstruction develops later, weeks or months after an attack of appendicitis, with well-developed fibrous adhesions and bands arising from the former plastic lymph.. No doubt fever of
some
an
of the bands which
obstruction
such,
and is
are
not
of
divides in
one
appendical origin,
therefore
following example definitely appendicular an
Less
of in
included
a
late
case
origin
in
but
a
of acute
case
as
not
this
proven The series.
of intestinal obstruction
:?
A male, aged 42, was operated on for suppurating appendicitis three months ago, the appendix was removed and the abscess drained. Attacks of abdominal pain with distension and vomiting followed. These were relieved by enemata, but tne attacks were recurring and becoming worse. On examination there was a well-marked incisional hernia* a tense and distended abdomen, a pulse of 100 and an anxious
expression. Operation was undertaken at once. Laparotomy was done through the previous scar in y1 Y right iliac fossa. The lowest foot of the ileum was bad kinked up by adhesions, the gut above being red and distende the colon empty and contracted. After freeing the adheSl? ,
>
the gut was raw over an extensive area, and it seemed proba that kinking might recur, so an ileo-cfecostomy was done short-circuit the kinked part of the ileum, the ventral was repaired in layers with overlapping. He n recovery. Later he developed acute cholecystitis.
her^ but u
Diagnosis.?Complete diagnosis may not be easy, ^ ^ less important in the primary cases, since in these Cllfe usually pretty clear that the condition is one 01 ^ abdomen," with signs pointing partly to obstruction ^ partly to some inflammatory affection and that opef< t is is urgently indicated. The only noteworthy point ^ open the abdomen by the paramedian incision rather r
"
o
'
j
APPENDICITIS AS A CAUSE OF INTESTINAL OBSTRUCTION.
in
the
have
27
right iliac fossa, so as to give plenty of room if adhesions
to be dealt with or an anastomosis
performed.
In the
post-operative type diagnosis may be difficult extremely important, as on the one hand one wants
and is
to relieve
a
true mechanical obstruction as soon
by operation, handle
really
the other
on
possible
as
does not want to further
one
and abuse inflamed intestine when the condition is
one
of
peritonitis
and ileus.
A sudden attack of
paroxysmal pain with rising pulse falling temperature, occurring in a patient who has been going on smoothly after the first operation, is fairly
and
suggestive vomit
of
when
obstruction
becoming
brown, with
cases there should be
a
delay
no
associated
with
bilious
soft abdomen, and in such in
opening
But where the condition is a mixture suppurative peritonitis diagnosis and
the abdomen.
of obstruction with treatment
are
alike
difficult. I he A
following is
girl, aged
a
good example of this type
15, with
a
history
of two
of
case :?
days.
At the first
patient
did well for
?Peration a gangrenous appendix was removed through a andiron incision, and as it was surrounded by foul pus the M?und
was
drained for two
days.
The
s?me days, then began to have irregular fever and per rectum ^gns of a pelvic collection. This was opened by a medium
day and proved to be of some size. large tube. Irregular pyrexia persisted, developed. The condition was not
on the thirteenth Incision was drained with a
ancf
faecal
a
fistula but there was 110 evidence of loculated pus. Wenty days later, i.e. thirty-three days from the first operation e patient had severe abdominal pain and vomited eight nies in the night, the temperature became subnormal and 10 markedly abdominal. third operation was done, a higher mid-line incision being an^ were broken down and a very small lo cu 1 ated many adhesions abscess found and drained. It did not appear to be Vory satisfactory operation, but the patient slowly recovered playing hockey three or four months afterwards. Se.emed to be mainly a case of fibrino-purulent peritonitis \vl Uc 1 1 developed obstruction.
satisfactory, /ace.
'
'
Tjv.as incidentally ?
28
MR.
.
RICHARD WARREN
Treatment.?In the
to several of the methods
is
fairly simple dividing
which
can
the
bands of recent
or
be done with the
onset do the adhesions
of
question
anastomosis.
finger; only require cutting.
further
When the
in the
types
More
such
treatment,
gut
already referred
In most instances it
possible. band
a
I have
quoted
cases
as
lymph, of later
important
is
drainage
or
above the obstruction is very
distended and the contents do not
readily
flow
past
the
of obstruction after its division the gut should be tapped with a medium trocar and gas and liquid faeces let
seat
puncture closed with purse-string suture. If the condition of the gut still appears doubtful a temporary fcecal fistula should be made, and I have found an ileostomy
out and the
of the
self-closing type quite satisfactory, using
catheter
as a
Where
a
a
No.
i2
drain.
large
amount of small
gut
is matted, and it is
rapidly become obstructed again, a short circuit should be done, usually an ileo-caxostomy to which a valvular caxostomy may with advantage be added in the more acute cases, as suggested by Handley some 1 anl years ago for the condition he calls ileus duplex. doubtful if it will not
doubtful of the
occurrence
of this condition
as
lie
describes
sigmoid at the same timeThe ileus is, however, certainly duplicated in many cases in another sense, I mean that there is peritonitic as well it,
viz.
a
block of the ileum and
ileo-caccostcmy with a caicostomy is very similar to that of a simple ileostomy* and possibly better where the patient will stand this further as
obstructive ileus.
The effect of
an
manipulation. same
subject
has
and
an
I have very similar to those his conclusions are very similar^ to miru>
in which he mentions
described,
the
interesting paper on appeared by Rayncr of Manchester,
Since I wrote the above
1
cases
II.M.J., i.. iy2.j,
p.
855.
APPENDICITIS AS A CAUSE OF INTESTINAL OBSTRUCTION.
29
except that in the treatment of post-operative obstruction he advises the use of stomach tube and morphia for one
proceeding to operation and quotes a successful case. Personally I think that twelve hours is long enough to persist in such cases unless marked improvement is noted, and should think that ileus relieved by such treatment is more probably peritonitic than true obstruction. Another paper bearing on this subject was from America. or
two
days
before
I have lost the reference.
drainage
in the
right
The author of this found that tube
iliac fossa
followed far less
was
operative obstruction than where the drain
mid-line. ment.
I have not
by post-
was
in
the
data to criticise this state-
enough
usually employed the gridiron incision and the post-operative cases have been drained, usually with the drain two days in the abdomen and a few more days ln the abdominal wall, i.e. all the post-operative cases followed a fairly severe peritoneal infection whether localised I have
?r not.
DISCUSSION.
Hie President thanked Mr. Warren for his dnd valuable
*^s
a
contribution,
physician
he would be
on
which discussion
glad
interesting
was
invited.
to hear whether Mr. Warren
c?uld recommend any measures that tended to prevent these post-operative obstructions. He recalled the late Mr.
Poole Lansdown's advocacy of practicable after operation
abdominal massage
??n as
^lexv to
preventing
the
occurrence
for
appendicitis
agnose from
Peristalsis
was
all other
^henfoiled, d
peritonitis
and from
the most conclusive means
of
obtaining
he had several times
with
a
of adhesions.
Mr. Rendle Shout remarked that these cases struction following appendicitis were often
0
as
ileus,
sign. an
seen
of intestinal difficult
to
and that visible In
cases
of
ileus,
action of the bowels lives saved
by
the
MR.
30 "
attack
triple
"
enema, and
oil,
ileostomy Mr.
dose of two
a
a
turpentine hypodermic of a
course, this will not avail
Of
if there
Under those circumstances
authentic obstruction.
an
giving
then four or five hours later
whilst it is still in the bowel
extract.
pituitary is
this consists of
;
minims of croton
RICHARD WARREN
under novocain anesthesia may be safer. pointed out that these
Ferrier Walters
operative diagnose,
obstructive adhesions and that he
were not
regarded
vomit
post-
seldom difficult to
becoming feculent,
48 to 72 hours free from this symptom, He preferred the as suggestive of inflammatory obstruction. pelvic drain, and had given up draining from the wound. after
It
an
was
interval of
important
to take care that
allowed to intervene between the bladder.
no
coil of intestine was
drainage
tube and the
He would like to hear from Mr. Warren how often
Sampson Handley's ileus duplex. incision, invariably used Battle's incision, cn females, where a doubt existed as to diagnosis, since this incision lends itself to such other operations as might -J prove necessary in cases in which the diagnosis proved incorrect. He used the gridiron, however, in men and children, as there is little liability to subsequent hernia, and one could get the patient up within a week. Mr. Chitty, referring to the suggestion that obstruction he had met with
cases
was more
than
of
he
As to the
often
when
Mc
that obstruction
seen
when Battle's incision
Burney's operation was
more
common
necessary, and he considered appendix from the inner side, as in more
often followed
by
when that
was
been
was
was
empl?}c^
performed, said pelvic drainage the
approaching
had Battle's incision, obstruction in his own cases a
1
adopted the gridiron incision, ana appendix more laterally. Consequently
than when he had
cO *
approaching the preferred the latter incision unless the presence of pdvlC un es suppuration was suggested by rectal examination, or
APPENDICITIS as a cause of intestinal obstruction.
some doubt
exploratory
as
to the
diagnosis
renders
a
more
31
extensive
incision advisable.
Mr. Tasker said that he had used Battle's incision in ?ver two
appendicectomies, and had only enpost-operative obstruction. He had c?me to the conclusion that if a drainage tube had to be Used, post-operative hernia more often followed McBurney's countered
hundred
two cases of
lncision than if Battle's incision was used. Mr. Lacy Firth stated that after using the gridiron lncision for many years he was led to adopt Battle's incision, which had the advantages in his opinion of giving a better exPosure
and of being easily extended for further investigal0n when the diagnosis was doubtful. He had not met
Wlth the
cases
which Mr. e had met
Peritonitis
of mechanical obstruction in acute
Warren had described.
appendicitis
The obstruction
with had been considered to be due to and treated
as
cases
spreading
such.
Mr. Richard Warren, in reply
an3 method adopted
to
points
raised
during discussion by various speakers, said that he believed it Was difficult to attribute the prevention of adhesions to e
to that end, and he doubted whether
massage of the abdomen avails or makes a material difference,
glii
^
lQugh early movements bed might be
of the
patient
while still confined
helpful. Mr. Short had referred to visible after operation as a valuable diagnostic Peristalsis but he had found visible peristalsis, at any rate in Cases, was somewhat late in appearing, and if present ^ould have no hesitation in opening up the abdomen ^ ?nce- The triple attack was too prolonged in action an aCU^e case requires quick operation, but for th ^ss acute the method might prove of value, though a decided objection to employing croton oil. Mr. Said he had not encountered ileus duplex, and he had cited Sampson Handley in this connection, soon
^CUte
"
th^011
"
MR.
32 he
did
seems
not
agree with
him.
have worked well.
to
tube in the
caecum one
faeces from the ileum inflammation of followed
WILFRID ADAMS
a
appendix.
In
obtained
through
retro-ccnecal
by adhesions
Nevertheless,
the
the
method
ileo-caecostomy with the direct rapid drainage of He
caecum.
appendix
than that of the
is
more
agreed that be
apt to usually located
more
