COMPLICATIONS ASSOCIATED WITH *

HENRY K. RANSOM, M.D. Associate Professor of , University of Michigan MedicaI School

ANN ARBOR, MICHIGAN

N a discussion of postoperative com- according to AIIen,2 is responsibIe for 94 per phcations CutIer and Scott’ state that, cent of the from this disease. The I “With the period that fohows opera- obstruction of the is usuahy due tive intervention begin the triaIs and to a fecaIith. The process advances rapidIy tribuIations of the .” This state- due to interference with the bIood supply ment is probably nowhere more true than of the appendix and consequent in the case of those patients who require of its waI1. Perforation may occur as earIy surgical attention because of a septic as four hours folIowing the onset of symp- appendix, and in whom has toms. Due to the sudden flooding of the extended beyond the confines of this unprepared with septic mate- . It is a we11 known fact that today the rial, Iittle opportunity is afforded for the mortaIity of for uncom- usua1 waIIing-off process to take pIace and plicated appendicitis is almost negh- a diffuse or genera1 ensues. gibIe, whereas in the more advanced cases, CoIIer and Potter3 found eighty-eight cases when peritonitis of some degree has super- of genera1 peritonitis among 336 patients vened, the mortaIity continues to be with acute appendicitis, in a11 stages of the disturbingIy high. For the most part, disease, admitted to the University of deaths from acute appendicitis are due Michigan HospitaI over a three-year period, to some phase of peritonitis either directIy, an incidence of 22.2 per cent. Stafford and as from toxemia, severe and iIeus, Sprong4 found 196 instances of genera1 or indirectIy from the Iater compIications peritonitis in a simiIar group of 1,3 17 of peritonitis, e.g., intestina1 obstruction, patients admitted to the Johns Hopkins , , etc. If one consuIts HospitaI over an eight-year period. The the records of the surgical cIinic in any incidence of peritonitis in this group was, Iarge hospita1, the more serious complica- therefore, 14.9 per cent. Barrow and tions of acute appendicitis wiII be found Ochsner” found 179 cases of general to incIude genera1 peritonitis, residua1 or peritonitis in a group of 1,039 cases of secondary , intestinal obstruction, acute appendicitis admitted to the Charity major wound sepsis, pneumonia, pyIephIe- HospitaI in New OrIeans, an incidence of bitis, Iiver , empyema, puImonary 17 per cent. The diagnosis of acute ap- embohsm, feca1 fistuIa, postoperative hem- pendicitis with genera1 peritonitis is not orrhage and thrombophIebitis. The present difFrcuIt. The patient compIains of severe discussion is concerned with the abdomina1 generaILed abdomina1 , with comphcations encountered in the manage- and . The becomes dis- ment of the perforated appendix and, in tended, tense and rigid. There is tenderness particuIar, with those which occur foIIow- throughout, aIthough it remains more ing operative intervention. marked in the right Iower quadrant. AuscuItation reveaIs a siIent abdomen. GENERAL PERITONITIS The temperature is considerabIy higher Diffuse peritonitis is most often the (IO I’F.) than in uncompIicated acute result of sudden perforation in the obstruc- appendicitis, and the p&e rate is increased tive type of acute appendicitis which, accordingIy. The Ieucocyte count is aIso * From the Department of Surgery, University of Michigan, Ann Arbor, Michigan. 102 NE\V SERIES VOI.. LVI. No. I Ransom--Appendicitis

high, e.g., 25,000 to 30,000. If the infection as many as 77.3 per cent of patients dying continues unchecked, the unmistakable of appendicitis. Fortunately, general peri- picture of a terminal peritonitis develops. tonitis is not one of the common post- The pulse becomes rapid and thready, operative complications. When it does there is profuse diaphoresis, the skin -is occur, it mav be due (I) to contamination cold and clammy, abdominal distention of the peritoneum by transperitoneal is marked, the eyes are sunken, the expres- drainage of abscesses, (2) to failure on sion is anxious and there is paIIor and the part of the surgeon to drain when cyanosis, signs which denote impending drainage is indicated at the time of the . It goes without saying that the most original operation, or (3) to an ill timed important treatment is prophylactic, i.e., operation whereby early- forma- recognition of the disease and removal of tion is interfered with; and what would be the appendix before infection has spread a localized infection if let alone, is con- beyond this viscus. The management of the verted into a spreading peritonitis. Occa- patient with general peritonitis remains sionally, because of an especially virulent a controversial matter. Many authors, type of infection, general peritonitis will (Horsley,6 Herrick,j Davis, Stafford and supervene regardless of the time and type Spron$ and others), advise prompt oper- of the original operative procedure. The ation regardless of the stage of the disease. subject of drainage is again a controversial It is our opinion that these patients with matter. The present day trend is to drain widespread or genera1 peritonitis are best less frequently than formerly, especially in treated by delayed operation and we cases in which a diffuse peritonitis is found recommend the Ochsner regimen in order at operation. However, the axiom, “When to improve the patient’s genera1 condition in doubt, don’t drain,” is capable of doing and to allow localization of the infection harm in the hands of young or inexperi- to take place before any operative proce- enced . Hanford”’ gives the follokv- dure is performed. However, we agree ing indications for drainage : with Allen and his associates that if one i I ) Any appendiceal abscess. With this sees these patients within four to six hours statement practically all authors agree. from the time of perforation, prompt Drainage is also advised when tissue of operation is best. By means of a careful doubtful viability must be Ieft in the history, very often the time of perforation , e.g., (a) necrotic tissue, can be determined. There is often an acute such as part of the wall of an abscess; increase in the severity of the pain fol- (b) part of the appendix; CC) the whole lowed bv a period of temporary relief. of the appendix; (d) damaged tissue. In such instances, while there is soiling of such as the meso-appendix stump, which the regional peritoneum and perhaps an might become necrotic in the presence of early local peritonitis, the peritoneum is infection. capable of handling this limited amount of (2) In acute diffuse peritonitis with infection, provided further contamination creamv purulent or fibrinopurulent is prevented by removal of the appendix. of considerable amount or with a malodor- Moreover, protective adhesions have not ous exudate. Some authors would disagree yet formed so that harm does not come with this statement. from an operation in this stage. (3) Insecure or doubtful closure of the As a postoperative compIication, general or the appendix stump. peritonitis must be regarded as one of the (4) An unrecovered Ioose . most serious since the mortality is aIways (5) Gross soiling by cecal contents. high. From their study of the literature, (6) Infection or contamination of the Ochsner, Gage and Garsideg concIuded that retroperitonea1 tissue as in a retrocecal peritonitis may be the cause of death in appendix. 104 American Journal of Surgery Ransom-Appendicitis

(7) UncontroIIed bIeeding or doubt as cIinica1 picture. In young and otherwise to the controI of bleeding. heaIthy aduIt patients, the usua1 picture As previousIy mentioned, genera1 peri- of genera1 peritonitis described above may tonitis may be the result of operative be observed. However, in eIderIy persons intervention which interferes with the or those weakened by their infection, fluid waIIing-off of a IocaI peritonitis folIowing and saIt imbaIance or by a proIonged perforation. In the case of a sIow perfora- operation invoIving excessive trauma and tion, as in the inflammatory type of hemorrhage, spreading or genera1 perito- appendicitis, the infection is effIcientIy nitis may exhibit a very atypica1 course. Iocalized if given a chance. In these Here the usua1 signs of peritonitis are sIow perforations, the defensive mecha- apt to be far Iess striking than usual. nisms of the peritoneum come into pIay There is commonly some abdomina1 dis- and prevent spread of the process by comfort and distention, associated with limiting the infection to the right Iower absence of peristaItic sounds. Nausea and quadrant or pelvis. Loops of intestine vomiting are common. The temperature and the omentum become adherent to may be high or, again, may be but sIightIy the cecum and appendix and adhesions eIevated. The puIse is rapid and Iater quickIy form. An abdomina1 mass may becomes thready and uncountabIe. There- become paIpabIe, aIthough this need not fore, in any patient who fails to do we11 be an abscess in the strict sense of this folIowing operation, the possibiIity of a term. The process terminates by progress- genera1 peritonitis shouId be considered ing to the stage of suppuration or, more and when suspected the usua1 regimen often, by spontaneous resoIution. Thus, (Ochsner) for the treatment of peritonitis in cases seen during the third, fourth or shouId be instituted. This consists in fifth day of the disease, with a mass FowIer’s position, hot appIications to the present or in the stage of deveIopment, abdomen, , IiberaI quan- operation is best deferred. If performed tities of , duodena1 syphonage, during this so-caIIed “danger period,” intravenous fluids, gIucose and sodium Love” points out that protective adhesions chIoride, bIood transfusions, oxygen and are broken down and a spreading or gen- drugs of the suIfonamide group. Secondary era1 peritonitis may thus be provoked. operations are rareIy indicated, as the Moreover, remova of the appendix under outcome depends chiefly upon the resist- these circumstances presents technical difi- ance of the patient and the viruIence of cuIties and is attended with the danger of the infection. As in any other case of to the cecum or intestine. Excessive peritonitis treated by the Ochsner regimen, bIeeding may be encountered and often carefu1 vigiIance is necessary in order to the procedure is proIonged and an undue detect IocaI abscesses as they deveIop. amount of trauma is inflicted. SimpIe When present, these shouId, of course, be drainage, on the other hand, is of IittIe drained at an early date. vaIue and corresponds to attempts at incision and drainage of a superficia1 SECONDARY OR RESIDUAL ABSCESSES ceIIuIitis whiIe stiI1 in the stage of brawny Secondary intra-abdomina1 abscesses are induration. By delaying intervention until prone to occur in certain fossae or regions the proper time, extraperitoneal drainage of the peritonea1 cavity. These abscesses of an abscess is possibIe or, in the case of may represent a favorable termination in spontaneous regression of the mass, a cIean cases of genera1 peritonitis which have appendectomy may be performed at a been treated conservativeIy and in which Iater date. the patient has succeeded in overcoming Spreading peritonitis induced by or his infection. In our experience, about foIIowing operation may present a variabIe 60 per cent of the patients with general peritonitis treated by the deferred opera- reason, residual abscesses in the mid- tive method, deveIop abscesses. Similarly, abdomen are uncommon. abscesses may be encountered in cases of Th e presence of a secondary intra- general peritonitis which have been treated abdomina1 abscess is often suggested by by prompt operation and they may develop the fact that following operation regardless of whether or not drainage was persists, or subsequent to a fall to normal, instituted and whether or not the appendix it suddenly becomes eIevated several dayIs was removed. Moreover, they may occur later. Along with this, the patient experr- as a postoperative following ences a certain amount of drainage in cases of a Iocahzed appendiceal or discomfort, the location of which abscess and here, again, regardIess of may be of some diagnostic value. If the whether or not the appendix was removed. process continues for a considerable time. It is for this reason that contamination the temperature curve exhibits septic of the uninvolved peritoneum shouId be swings and the patient appears worn and avoided, and that extraperitoneal drainage haggard from the effects of the continued shouId be performed whenever possible. sepsis. He feels weak and exhausted, has Rarely such abscesses may develop as a and malaise and later may develop comphcation of appendectomy when only a secondary anemia. a local peritonitis was present at the time reveals localized tenderness on abdominal, of operation. C. W. CutIer, Jr.,12 in a study rectal, or vaginal examination and a mass of 1,65 I patients with acute appendicitis may be palpable. in the sub- operated upon at the Roosevelt Hospital, phrenic spaces are more difficult to detect found secondary abscesses which required and require speciaI attention and study. further surgery’ in thirty-three patients. Pelvic Abscesses. Abscesses situated in Such abscesses were found in 4.5 per cent the rectovesical or recta-uterine pouches of al1 cases of suppurative appendicitis. are the most common of the residual In this group of thirty-three cases, about abscesses. In fact, this is the most desirable 60 per cent followed genera1 peritonitis, location for such abscesses and one of the whereas the remainder occurred as a com- advantages of the Ochsner regimen in the plication of suppurative appendicitis with treatment of peritonitis, either independ- local or spreading peritonitis. In his series ently or in conjunction with operation, is the mortality was 21 per cent in the entire the assistance which it renders in locnlizn- group, or 13 per cent if the subphrenic tion of the general infection in the pelvis. abscesses were excluded. With the patient in the recumbent position, As shown in Figure I, the common sites the cul-de-sac becomes the most dependent for these secondary or residua1 abscesses portion of the peritoneal cavit).. Whether are ( I) the pelvis, in which case the abscess the factor of gravity aIone is important in occupies the cul-de-sac of Douglas, (2) alIowing to settle in the pelvis the left lower quadrant, (3) the sub- is problematical. Nevzertheless, Fowler’s diaphragmatic spaces, and (4) the iIeoceca1 position is one of maximum comfort for region. True residua1 abscesses foIIowing the patient and when abdominal distention genera1 peritonitis are often found either is marked, it relieves pressure on the in the pelvis or in the subphrenic spaces. diaphragm and thus diminishes respiratory This is due to the fact that with the patient embarrassment. The old view that absorp- in the recumbent position, the marked tion is less rapid from the pelvis than from anterior convexity of the Iumbar spine the diaphragmatic peritoneum, is no longer tends to deflect puruIent exudates upward tenabIe. In the peIvis, however, there is a or downward, aIIowing collections to form minimal amount of movement, whereas in the more dependent or isolated recesses in the subphrenic spaces, 1ocaIizntion is of the peritonea1 cavity. For the same interfered with through the constant mo- 106 American Journal OFSurgery Ransom-Appendicitis AWL, ,g.p tion of the diaphragm. AI1 agree that morphine are among the most important IocaIization of infection in the pelvis is items in this regard. GastroduodenaI suc- much to be preferred to IocaIization in the tion and the intravenous administration

FIG. I. Diagrammatic sketch FIG. 2. Diagram showing method FIG. 3. A short Iongitudinal showing the more common of confirming diagnosis of incision has been made Iocations of the residual or abscess in the rectovesica1 through the anterior wall secondary intraperitoneal ab- pouch. If is obtained on of the at the site scesses associated with ap- aspiration, drainage by rec- of the needle puncture Dendicitis. (Redrawn from turn is then instituted. and a stiff rubber tube in- bchsner, A., ‘Gage, I. M. and serted. The tube is heId in Garside, E. The intra-abdom- pIace by means of one su- ina postoperative compIi- ture through the recta1 cations of appendicitis. Ann. wall. The end of the tube SW?, 91: 544, 1930.1 is left Iong and extends out through the anus. subphrenic or subhepatic spaces, since of soIutions of gIucose and sodium chIoride in the pelvis recognition of an inflam- are vaIuabIe adjuncts. Under conservative matory mass or abscess is far easier and, therapy, over one-half of such peIvic aIso, since here surgica1 drainage, shouId masses wiI1 subside and no operative inter- it become necessary, is a simpIer procedure. vention wiI1 be necessary. It is common experience that the mortaIity Diagnosis. A peIvic abscess shouId aI- of peIvic abscesses is Iower than that of ways be suspected in any patient who, abscesses situated in the upper quadrants foIlowing operation, continues to run a of the abdomen. As in the case of IocaIiza- septic course. Wound infection and other tion of infection at any other point in the causes of fever, e.g., , peritonea1 cavity, the presence of an pneumonia, thrombophIebitis, etc., shouId, inflammatory mass or area of inf3tration of course, be considered and excIuded. Ab- does not necessariIy denote a true abscess. scess formation in the cuI-de-sac is aIways It is onIy when suppuration has taken pIace to be Iooked for in patients being treated that surgica1 drainage is indicated. The conservativeIy for genera1 peritonitis. DaiIy majority of these inflammatory masses recta1 examinations shouId be made. An wiI1 undergo spontaneous resoIution under inffammatory mass or infiItration is easiIy proper conservative treatment and such feIt as a hard, firm, tender tumor mass treatment shouId first be given a thorough buIging into the upper rectum anteriorIy. tria1. The principIes invoIved are essentialIy It is usuaIIy feIt at the tip of the examining those entaiIed in the treatment of genera1 finger. Subjective symptoms referabIe to peritonitis. Restriction of a11 food and the bIadder, e.g., dysuria, urgency or fluid by mouth and the IiberaI use of frequency may be present. In the Iater NI w SERIES Vol.. I.VI, NC,. I Ransom--Appendicitis stages, is not uncommon. Re- scesses in the left Iower quadrant of the peated digital examination of the rectum peritoneal cavity occasionahy occur but wiII enabIe the surgeon to foIIow changes are relativeIy uncommon. They are encoun- in the size of the mass. Thus it may dimin- tered more frequentIy as a postoperative ish, an indication of spontaneous resoIution, compIication than in patients undergoing or it may enIarge downward. Areas of conservative treatment for genera1 perito- . . softening indicative of suppuration shouId mtrs. Barrow and Ochsner call attention be sought for. Large cul-de-sac masses to the fact that abscesses in this IocaIitJ may arise out of the pelvis and then become are seen only in patients with a shallow palpable on abdomina1 examination. As pelvis and that they are most often found suppuration occurs in a pelvic mass, the in chiIdren. They frequently are associated anal sphincter relaxes and the anus be- with an abscess which fills the pelvis and comes patulous. The recta1 mucosa becomes then extends upward and points to the edematous and succuIent and has a soft, left. The genera1 are thick, velvety feel. When these findings are those of any other secondary or residual encountered, surgica1 drainage is indicated. abscess plus the localizing signs of tender- In general, our preference is for abdomina1 ness, possible muscle spasm and skin drainage and this should be performed in edema, and a paIpabIe mass in the left the extraperitoneal manner. Many sur- Iower quadrant. The principles of treat- geons, however, more or Iess routinely ment are similar. Here, again, it should advise drainage by way of the rectum or be mentioned that many will subside vagina. In rectal puncture there is aIways spontaneously. If suppuration occurs, the danger of injury to the great vessels drainage will be necessary and is best of the pelvis. The bIadder may also be performed through a small muscle splitting injured during this procedure and Stafford incision, taking care to avoid contamina- and Sprong report a fatahty due to this tion of the main peritoneal cavity. As a accident which was folIowed by a persistent rule, there is no great urgency for surgical rectovesical hstula and a fatal ascending intervention and, before proceeding with infection of the urinary tract. In our opin- surgery, one should be certain that sup- ion, rectal drainage should be reserved puration has taken pIace and ample time for those peIvic abscesses which are Iarge should be aIlowed to be certain that firm and which point low down in the rectum, adhesions are present, in order that these and in which a large area of softening can protective barriers are not broken down be demonstrated. When this is the case, in the process of drainage. the diagnosis is first confirmed by aspiration Subdiaphrapmatic Abscess. Suppurative of the abscess with a Iarge gauge needle. disease of the appendix is responsible for (Fig. 2.1 The bladder having been emptied more instances of subphrenic abscess than prev.iously, the patient is pIaced in the Ii- any other single Iesion. Ochsner and De- thotomy position. If pus is obtained on Bakey’” in their anaIysis of 3,533 cases of aspiration, drainage of the cavity is estab- subphrenic abscess, collected from the lished by making a vertica1 incision in the world Iiterature, found lesions of the anterior rectal wall at the site of the needle appendix to be the etioIogica1 factor in puncture, evacuating the pus and inserting 30.9 per cent, and in 25.3 per cent of their drains. (Fig. 3.) In propedy selected cases, own seventy-five cases. In I 5,000 collected this is a very simpIe technica procedure cases of acute appendicitis, they- calculate and provides an efficient form of drainage. that subphrenic abscesses occurred as a Undrained cul-de-sac abscesses may spon- complication in 0.9 per cent. The!. em- taneously rupture into the rectum and phasize the point that many subphrenic thereby undergo spontaneous cure. infections do not progress to the stage of Left Lower Quadrant Abscesses. Ab- abscess and, aIso, the fact that due to 108 American Journal of Surgery Ransom-Appendicitis diff&Ities in diagnosis many subphrenic hepatic space into right and Ieft spaces of abscesses are never recognized. Faxon, l4 approximately equa1 size. The right supra- in a recent communication, reported 124 hepatic space is divided by the IateraI consecutive operative cases of subphrenic extension of the cardina1 Iigament of the abscess at the Massachusetts Genera1 Iiver, i.e., the right IateraI Iigament into HospitaI, and found the etioIogy to be a a large right anterior superior space and a lesion of the appendix in thirty-eight, or smaIIer posterior superior space, Ieaving a 31 per cent. WeIIman and Maddock,lj in a singIe Ieft superior space. The infrahepatic review of fifty-two cases of subphrenic space is aIso divided into right and Ieft abscess, observed at the University of haIves by the round Iigament and the Michigan Hospital over a ten-year period, ligament of the ductus venosus. WhiIe found that twenty-one, or 40.3 per cent, there is but one right inferior space, on the occurred as a compIication of appendicitis. Ieft side and separated by the and The mechanism whereby infection may gastrohepatic omentum are the Ieft ante- reach the subdiaphragmatic spaces from rior inferior and the Ieft posterior inferior the somewhat distant right iIiac fossa is of spaces. interest. The route most often described The right posterior superior space is the is that of direct extension aIong the right one most commonIy invoIved in a11 sub- paracolic gutter. Overholt, l6 by experi- phrenic abscesses, and this is especiaIIy mentaI studies, has demonstrated the true in those infections of appendicea1 fact that a negative pressure is created origin. Thus Ochsner and DeBakey found in the upper abdomen by respiratory in a review of 1,461 cases of subphrenic movements, and this wouId tend to cause abscess that the right posterior superior septic materia1 to be aspirated upward space was invoIved in 33.7 per cent, and in and into this region. ConsiderabIe attention 44.7 per cent of their own seventy cases. has been given to the possibiIity of exten- In Faxon’s study, the right posterior sion by way of the Iymphatics by Munro,17 superior or right inferior spaces were Barnard l8 and TruesdaIe.lg invoIved in 66 per cent of the cases in In orier to appreciate fuIIy the signifi- which the infection originated in the cance of subphrenic infections, a brief appendix. Subphrenic abscesses may be review of the anatomy of the region is residua1, as in cases of a resoIving genera1 necessary. FoIIowing the earIier descrip- peritonitis, or secondary when infection tions by MartinetzO and Barnard,21 the has extended from the appendix to the term subphrenic region has come to denote peritoneum but when genera1 peritonitis that space in the upper abdomen bounded has not occurred. With regard to diagnosis, superiorIy by the diaphragm and inferiorIy the condition is suggested by continued by the transverse coIon and mesocoIon. evidence of sepsis (fever and Ieucocytosis) Thus, subhepatic abscesses properIy be- in a patient known to have had a IocaI or Iong in this group. DetaiIed descriptions general appendicea1 peritonitis and in of the anatomy of the region are found in whom evidence of a suppurative process the exceIIent treatises by 0chsner,22’23s24 eIsewhere in the abdomen, as we11 as extra- Nather and 0chsner,25 Ochsner and De- abdomina1 causes for fever have been Bakey, Ochsner and Graves,26 and by excIuded. Faxon stresses the foIIowing Faxon. The main subphrenic space is points in the history and examination: divided by the Iiver into a suprahepatic (I) tenderness over the tweIfth rib or and an infrahepatic portion. Each of these lower Costa1 margin, sometimes best elicited compartments is in turn subdivided into by compression of the thorax, (2) findings three smaIIer spaces. Passing from the indicative of a high, fixed diaphragm on the diaphragm to the Iiver, the faIciform affected side, and (3) manifestations of suspensory Iigament divides the supra- diaphragmatic irritation, e.g., pain referred NEW SERIES VOL. LVI, No. I Ransom--Appendicitis American Journal ot’ Surxcry 109 to the shoulder or neck, hiccoughs and duced into the abdominal cavity. and since discomfort on deep respiration. The it may remain unabsorbed for as long as is often displaced downward. two weeks, its presence may confuse the

A B

FIG. 4. A, roentgenogram in anteroposterior projection showing the appearance in a late case of subdiaphragmatic abscess. The right diaphragm is elevated and a large gas bubble is seen beneath the diaphragm. R, Iateral projectron in same case as ,A.The large collec- tion of gas under the diaphragm is shown. The roentgenoIogica1 examination will picture. At the present time most authors assist materially in the diagnosis, although condemn the practice of aspiration of the the roentgen findings are not pathogno- subphrenic spaces as a diagnostic proce- manic unti1 the late stages when a gas dure. It is an unreliabIe method, as failure bubble and ff uid IeveI can be demonstrated. (Fig. 2.) However, in conjunction with consistent cIinica1 findings, roentgen evi- dence of a high fixed diaphragm and an associated pIeural effusion calls for a presumptive diagnosis of subphrenic ab- scess. (Figs. 3 and 4.) In order to be of the greatest assistance, particularly in the localization of the infection, the roent- genoIogica1 study shouId include, in addi- FIG. 4. c, anteroposterior projection, with tion to the usua1 anteroposterior fihns, patient lying on left side. The Iargc collection lateral views as well as Auoroscopic ex- of air is shown and a definite lluid level is amination. (Fig. 3.) In the case of patients present. The irregular shadows in this Film at the left are due to the injection of Iipiodnl into who continue to have unexplained fever a sinus tract resulting from a previous un- folIowing perforation of the appendix, it successful attempt at drainage. is our practice to have roentgen studies of the diaphragm every third day since, to obtain pus does not exclude abscess. in such instances, the possibiIity of infec- Moreover, the danger of contamination tion in the subphrenic spaces must always of uninvoIved portions of the peritoneum, be borne in mind. It is to be remembered the pIeura, or both, cannot be minimized. that at the time of Iaparotomy or ab- When, however, the question is one of dominal , air may be intro- between subphrenic I IO American Journal of Surgery Ransom-Appendicitis abscess and empyema, a carefuIIy per- They are most IikeIy to occur when, due to formed thoracentesis is not objectionabIe. errors in judgment, drainage was omitted Ochsner and DeBakey suggest that ap- at the time of the origina operation. In

FIG. 5. Early roentgen findings FIG. 6. Roentgenogram in case of FIG. 7. Roentgenogram in in a case if subdiaphragmatic right subphrenic abscess with case of subdiaphragmatic abscess. The right diaohrarm an unusuaIIy extensive asso- abscess involving the right is eIevated and there-is par- ciated pIeura1 effusion. In this anterosuperior space. This tia1 obliteration of the costo- case, repeated thoracenteses shows the vaIue of the Iat- phrenic suIcus due to pleura1 were performed before the cor- era1 projection in the effusion. FIuoroscoov. ., showed rect diagnosis was made. It was localization of the abscess. the diaphragm on this side after these were done that the to be immobiIe. ff uid IeveI appeared, due to the air introduced at the time of the taps. CuItures of the fluid were consistentIy negative. proximateIy 75 per cent of the cases of the earIy.stages before a definite mass has subphrenic infection wiII subside spon- deveIoped, they may be confused with a taneousIy under conservative measures, wound infection. The symptoms and signs and suppuration demanding surgicaI drain- may be similar. In each there is continued age wiII occur in onIy 25 per cent. They fever, tachycardia, Ieucocytosis, pain, ten- beIieve that when the aforementioned derness, sweIIing and induration in the findings suggesting subphrenic space infec- neighborhood of the wound. Later, in the tion fai1 to subside within a week, it is case of an iIeoceca1 abscess, an intra- justifiabIe to assume the presence of an abdomina1 mass becomes recognizable. In abscess and to proceed with surgery. In either case, whether Iocalized intraperi- cases in which the diagnosis remains in tonea infection or wound sepsis, the earIy doubt, expIoratory operation is advised treatment is conservative, i.e., hot wet by them since, if performed extraserously, dressings, physioIogica1 rest and chemo- the risk is sIight. The technica procedures therapy. If an intra-abdomina1 abscess is for extraserous drainage are we11 described suspected, the usual conservative measures in the papers by Ochsner devoted to this for peritonitis shouId be empIoyed in order matter. Undrained subphrenic abscesses to faciIitate IocaIization and to minimize may rupture through the diaphragm, with the danger of spread of infection beyond the a resuItant empyema, bronchopIeura1 fis- right iIiac fossa. Under these conditions tuIa, pneumonia or Iung abscess. the mass becomes more IocaIized and Iater Right-sided or Ileocecal Abscess. These may increase in size if suppuration occurs. IocaI abscesses are reIativeIy uncommon as Suppuration is discIosed by the presence postoperative compIications, especiaIIy in of softening or possibIy fluctuation, whiIe cases where drainage has been empIoyed. the temperature chart reveaIs a “picket NEW SERIES VOL. 1 VI. No. I Ransom--Appendicitis fence” type of curve. When this takes accident which is almost invariably fatal, place, surgica1 drainage is indicated. How- as the unprepared peritoneum is then sud- ever, the operation shouId not be per- denIy flooded with septic material and an formed until one is certain that the sur- overwhelming infection of the peritoneum rounding adhesions are sufficiently strong ensues. Again, such an undrained abscess so as not to be broken down easily, since may burrow into the mesentery and cause contamination of the remainder of the erosion of a large vessel, \vith peritoneal cavity must be avoided and disastrous results. every effort should be made to perform an extraperitoneal type of drainage operation. DISORDERS OF THE LIVER In cases of general peritonitis, treated con- and . Fortu- servatively by the Ochsner regimen, the nately, hepatic abscesses occur but rarely right iliac fossa is a common site for as a complication of the septic appendix, localization of the infection and subsequent but constitute a most serious problem abscess formation. The diagnosis and treat- when present. The mode of spread of infec- ment of these abscesses are essentially the tion whereby suppurative appendicitis is same as in the case of those which occur responsible for hepatic abscesses is most postoperatively. It is important to note often by way of the portal vein, i.e., follow- that the majority of abscesses encountered ing pyIephIebitis. A less common cause is in the right lower quadrant occur not as a extension to the liver from a subphrenic postoperative complication, but rather space infection or abscess. Ochsner, De- primarily following the sIow perforation Bakey and Murray,“” in a series of 575 of an infected appendix. Far more common cases of pyogenic abscess collected from than the true abscesses, are the inflam- the Iiterature, found 197, or 34.2 per cent, matory masses or infiltrations in this to be secondarv to appendiceal disease. region, and a distinction between these In their own series of forty-seven cases of two lesions should be made. In the treat- , live, or 10.6 per ment of such inflammatory masses, whether cent, were due to appendicitis, while in true abscesses or inflammatory infiItrations, their personal series of 5,293 cases of acute Lehman and Parker28 advocate conserva- appendicitis over a ten-year period, there tive therapy. During the years 1936 to were five instances of secondary liver 1937, 83.3 per cent of their abscess cases abscess, an incidence of 0.094 per cent. were treated along conservative Iines and The liver abscesses complicating acute 65 per cent were carried through without appendicitis are usually multiple, and the operation. Under certain conditions they right lobe is more commonly involved than found it necessary to abandon conservative the left. Occasionally, small abscesses may therapy and resort to surgica1 intervention. coalesce to form a large solitary abscess. Such operative procedures are classed as The usual clinical picture of pylephle- “forced operations.” They regard as indi- bitis and liver abscesses complicating acute cations for a forced operation during the perforated appendicitis is characterized by course of conservative treatment, acute high fever and chills, usually of abrupt intestinal obstruction, or growth in the size onset. There is localized pain and tender- of the abscess, with threatened perforation ness in the region of the Iiver. The liver is into the anterior abdominal wall or rectum emarged. In the study of Ochsner, De- along with an associated increase in the Bakes and Murray, jaundice proved to be signs of sepsis. It has been pointed out by a less common finding than is generally Wangensteen”!’ that prolonged delay in supposed. These authors found jaundice to draining large abscesses is attended with be present in only 36.4 per cent of their certain dangers, since such an abscess may collected cases, and 24.7 per cent in their rupture into the free peritoneal cavity, an own series. When present, it was a late I I2 Amerrcan Journal of Surgery Ransom-Appendicitis deveIopment and they regard its presence bIeeding due to hypothrombinemia oc- as of grave prognostic import. Koster31 curred. This, they beIieve, was due to emphasizes the importance of spIenomegaIy disturbed Iiver functions consequent upon and tenderness along the course of an acute which, in turn, was due the porta vein as of diagnostic significance. to severe intraperitoneal sepsis. Since, The Ieucocyte count is often unusuaIIy under such circumstances, such bIeeding high, with a proportiona increase in the may resuIt in marked Ioss of brood and percentage of poIymorphonucIear Ieuco- extension of infection, they recommend cytes. Roentgen studies are of value and frequent plasma prothrombin determina- show eIevation and fixation of the dia- tions in cases of peritonitis. Since the phragm, particularly the right. In the series hypothrombinemia is due to a depression of Ochsner, DeBakey and Murray, a posi- of Iiver function, the administration of tive roentgen diagnosis was made in vitamin K is Iess effective than usual and, twenty-three of twenty-eight cases exam- therefore, in addition to its use, repeated ined roentgenoIogicaIIy, or an incidence of bIood transfusions shouId be given. 82.1 per cent. Koster suggests the use of thorium dioxide (thorotrast) in cases in which there is doubt of the diagnosis, and IIeus, as a postoperative complication, aIso for the purpose of determining the may be of two types, (I) acute mechanica character and extent of the suppurative intestina1 obstruction and (2) adynamic or process in the Iiver. He administers the paraIytic ireus. A distinction shouId be drug intravenousIy in doses of 23 cc. on made between these two types, aIthough in three successive days, foIIowing which some instances the two may co-exist. roentgenograms are taken. In norma per- VanBeuren33 reports that of 130 patients sons the x-ray shadow of the Iiver is of with acute iIeus operated on at the New uniform density. An abscess wiI1 appear York Presbyterian HospitaI from 1932 to as an area of Iesser density, and in multiple 1934, eight, or 6 per cent, occurred as abscesses the Iiver shadow wilI show a compIications of acute appendicitis. The mottled appearance. Judging from the incidence of Iate obstructions due to ad- reported cases, this procedure seems to be hesions foIIowing operations for acute of vaIue as far as accuracy of diagnosis is appendicitis would be considerabIy higher. concerned. However, sufficient evidence VanBeuren aIso found that in 380 patients has not yet accumuIated to determine with acute appendicitis coupIed with acute whether or not thorotrast is entireIy with- diffuse peritonitis operated on at the out danger. Most authors condemn ex- Presbyterian HospitaI between 19 I 6 and pIoratory puncture of the Iiver in doubtfu1 1938, acute iIeus deveIoped as a post- cases. WhiIe the prognosis of pyogenic operative compIication in twenty-eight abscess of the Iiver is decidedIy bad, this cases, or 7.4 per cent. This author reports is particuIarIy true in the case of muItipIe a mortaIity of -56 per cent in a series of Iesions, the type most often found in asso- thirty-four cases of acute iIeus complicat- ciation with appendicitis. Thus in the ing acute appendicitis with abscess or series reported by Ochsner and his asso- general peritonitis. In this group of cases, ciates, the mortaIity for singIe abscesses the mortaIity of the mechanical type of was 37.4 per cent in contrast with a mor- iIeus was 47 per cent, whereas that of the taIity of 95 per cent in the cases in which paraIytic type was 63 per cent. muItipIe abscesses were present. Acute Mechanical Obstruction. Due to Acute Hepatitis. Simeone and Stewart32 adhesive bands, a Ioop of bowe1, usually report two cases of acute appendicitis with the termina1 iIeum, may be caught and perforation and general peritonitis in anguIated so that a mechanica obstruction which, during the postoperative period, is produced in cases of IocaIized or genera1 NEW SERIFS VOL. LVI, No. I Ransom--Appendicitis

peritonitis. While these recent light ad- tance. The simple flat plate or scout film of hesions are unlike the dense, firm adhesive the abdomen, taken with the patient in the bands seen in late adhesive obstructions, supine position, is usually sufficient. The nevertheless they are entirely capable of administration of barium by mouth is causing compIete mechanical blockage to absolutely contraindicated and a very ill the flow of the intestinal stream. This is patient should not be subjected to com- made possible because of the fact that in plicated or prolonged examinations. W’an- peritonitis, and especially in patients hav- gensteen a4 has pointed out that while gas ing had an operation involving an unusua1 is normally present throughout the gastro- amount of trauma or manipulation, there intestinal tract, it is visualized in the x-ray is associated some degree of paralytic iIeus. film of the abdomen only in the stomach Due to the consequent Ioss of the normal and colon, except in the case of patients propulsive power of the intestinal muscle, under three years of age. In the small intes- the coils become dilated with fluid and tine, while gas is present, it is so intimately gas and a dangerous angulation at the mixed with fluid that it is not visualized point of fixation occurs. Great distention of under conditions of normal peristaltic the bowel interferes with its blood supply activity. When stasis occurs due to me- and, if not corrected, may Iead to necrosis chanical or functional ileus, the fluid and of the wall with perforation. Many of the gas separate and gas can be demonstrated. postoperative obstructions, therefore, rep- If ileus is present, dilated small bowel may resent a combination of mechanica and be seen within a few hours following the adynamic ileus. onset, and subsequent Urns may demon- While the diagnosis of small intestinal strate a progression of the process. Dilated obstruction due to adhesive bands but small bowel is recognized by its central occurring weeks, months or years after position, its feathery cross striations and operation is ordinarily easily made, the the transverse position of the parallel recognition of this type of obstruction coils. (Fig. 8.) The presence of many coils which occurs during the postoperative suggests a low obstruction, and any great period may be more difficult. Here, as in degree of asymmetry suggests a mass as postoperative genera1 peritonitis, the symp- the cause of the displacement. (Fig. 9.) By toms may be relatively mild and insidious. means of the roentgenogram alone, it is They often are overshadowed by per- impossible to distinguish between me- sistence of the symptoms and signs of the chanical and adynamic ileus. Blood chem- original peritomtrs. Thus abdominal pain istry studies show an increase in the and obstipation are difficult of evaluation. nonprotein nitrogen, a fall in the plasma However, during the postoperative period, chlorides and usuallv an increase in the any increase in pain, especially if it is carbon dioxide combming power. In these colicky and cramp-Iike in character, should early postoperative adhesive obstructions, be the cause for concern. Nausea and treatment by gastroduodenal suction after vomiting, if persistent and severe, should the method of Wangensteen”:’ or, pref- suggest mechanical or paralytic ileus. The erably, by the use of the “long” Miller- presence of “ fecal ” vomiting is indicative Abbott tube, is eminently successful. In of a low obstruction. Abdominal distention this type of case, in the past, simple is due either to mechanica or adynamic enterostomy usually effected a prompt ileus. In mechanical obstruction, ausculta- cure. The decompression of the distended tion reveals active peristalsis. This exami- coils of bowel above the obstruction served nation Iikewise is of less vaIue than in those to release the kink at the site of fixation patients who are not convalescing from an and, with the resumption of peristaltic abdominal operation and peritonitis. X- activity, this complication was corrected. ray examination is of the greatest impor- At the present time, intestinal suction 114 American Journal of Surgery Ransom-Appendicitis APRIL, 1942 achieves the same resuIt by means of what diIates and remains motionless. It becomes might be termed as “interna enterostomy” fiIIed with its norma secretions and, since and surgica1 intervention is rareIy neces- these are not moved onward, upper gastro-

FIG. 8. “Scout film” of abdo- FIG. 9. “Scout film” of men in case of small intes- abdomen showing tina grade obstruction ofhg shows ,;:;::;;:&,a:;: smaI1 howe with gaseous ment and transverse posi- distention of the iIeum and tion of the intestina1 coils . There is an ab- and their centra1 Ioca- sence of bowe1 pattern in tion in the roentgenogram. the right Iower quadrant, The fine cross-striations are suggesting the presence of characteristic of diIated a mass at that point. smaI1 intestine. sary. OccasionaIIy, in low obstructions in intestina1 stasis ensues. Due to reverse which adequate decompression is impos- peristalsis, vomiting foIIows. Pain ordi- sibIe by means of duodena1 suction and in narily is not severe or characteristic. The which technica diffIcuIties are encountered abdomen is distended and is silent on in the passage of the MiIIer-Abbott tube auscuItation. Due to pressure on the dia- beyond the pyIorus or the Iigament of phragm, respiration may be embarrassed. Treitz, enterostomy may be necessary in As aIready mentioned, mechanica and order to avoid further deIay and, in the functiona ileus may frequently co-exist. very III patient, to avoid the exhausting The treatment of adynamic ileus is the effects of repeated fluoroscopic manipula- treatment of the underIying peritonitis. tions. StiII Iess frequentIy, gastroenteric The patient shouId be kept in the FowIer’s suction may fai1 to relieve the obstruction position. Here, the use of duodenal suction and reoperation becomes necessary in the by the method of Wangensteen is of the event that it is due to some unreIated greatest value. GastroduodenaI suction condition. serves to keep the upper portion of the Adynamic Ileus. Adynamic, paraIytic digestive tract free of gas, swaIIowed air or functiona iIeus is an accompaniment of and retained secretions. Drugs such as peritonitis and may be regarded as a pro- eserine or pituitary derivatives are con- tective mechanism insofar as, with its traindicated because of the danger of occurrence, peristaItic activity ceases. spreading infection if vioIent peristaIsis Here, there is no single point of occIusion is stimulated. Moreover, they are ineffl- of the lumen of the bowe1. Due to the loss cient in restoring the normal tonus and of its contractiIe power, the intestine rhythmical contractions of the bowel. Nrw SERIES Vm.. LVI, No. r Ransom-Appendicitis

Morphine, on the other hand, has a stimu- perforated appendicitis to be the etiological lating effect upon the intestinal muscula- factor in ten of the thirty-seven cases of ture by increasing tone and rhythmic abdominal fistulas reported by them. These contractions, as shown by 0rr.36 Since it authors state that the most common cause also minimizes the discomfort of the of intestinal fistula is an infection which indwelling duodenal tube and the intra- produces gangrene and perforation of the venous needles, it shouId be used freely. bowe1 and that, in their experience, cecal Plasma chlorides should be maintained at fistulas usuaIly were the result of a direct a normal level. 0chscner37*38’3g recom- extension of an infection of the appendix mends heat applied to the abdomen by to the cecal wall, with a resultant slough- means of body bakes. He beIieves that, due ing of the wall. Fistulas involving the small to the vasodilatation produced in the intestine were more often the result of abdominal wall, there is a reciprocal vaso- secondary operations for pelvic abscess or constriction in the splanchnic areas which, intestinal obstruction and were due to in turn, has a beneficia1 effect upon dis- injury to the small bowel at the time of tention. Distention may aIso be combated operation. Dixon and Deutermanll tnen- by oxygen therapy employing high concen- tion that a fecal fistuIa may follow drainage trations of oxygen as recommended by of an appendiceal abscess in cases in which Fine.l” As the body defenses begin to the appendix is not removed at the original overcome the infection, the tone and operation, since a fecalith in the remaining activity of the bowe1 will return to normal. portion of the appendix may cause the development of such a fistula. Probably in FECAL OK INTESTINAL FISTULA some cases an unrecognized and unrelieved Fecal fistula is an uncommon complica- intestinal obstruction in the terminal tion of operation for acute appendicitis, results in perforation of the bowel at the either with or without an associated point of the obstruction, whereupon a peritonitis. In a series of ninety-four cases fistula ensues. of intestinal fistula seen at the University Because it is believed by some surgeons of Michigan HospitaI between the years of that postoperative fistulas are due to 1925 and 1934, and studied by Ransom and improper treatment of the appendiceal Coller,al thirty, or 32 per cent, developed stump, there has been much discussion in following operations upon the appendix. the literature regarding the merits and dis- Eight of these developed in the hospita1 advantages of invagination of the stump at following operation. In a11 of them the the time of appendectomy. Some authors infection had extended beyond the appen- maintain that such a technic is responsible dix at the time of the origina operation, for a high incidence of fecal fistulas, and there was either a local abscess or a whereas it is contended that simple ligation general peritonitis. These eight feca1 fistuIas without invagination reduces this inci- occurred among 234 cases of acute appen- dence. It has been our practice to invert dicitis with abscess or general peritonitis, the stump with a purse-string suture of and which were treated by operation, an catgut or silk, or by means of three incidence of 3.4 per cent. The incidence of mattress sutures of silk whenever the con- fistulas for the total number of operations dition of the cecal wall will permit this for acute appendicitis with and without procedure. We have seen no instance of perforation (1,067) was onIy 0.8 per cent. fecal fistuIas which we could attribute to In a series of 109 fecal fistulas observed in invagination of the appendiceal stump, and the Johns Hopkins Hospital over a period similar experiences are recorded by Lewis of forty years, Lewis and Penick42 found and Penick and by Dixon and Deuterman. that forty-nine, or 44.9 per cent followed Some fistulas are caused by the use ot appendicitis. Marshall and Lahey43 found improper drainage materials. Fortunately, 116 American Journal of Surgery Ransom-Appendicitis APRIL, xo~ glass and hard rubber drains, once so tend to heaI spontaneously. This is par- commonty used, have been IargeIy super- ticularly true of the ceca1 hstulas. When seded by drains of soft rubber, gutta- healing fails to occur in these cases there is percha, or drains of the cigarette variety. usuaIIy an outgrowth of the cecal mucous A heavy gauze drain aIIowed to remain in membrane so that it becomes continuous contact with a suture line is apt to pro- with the skin, producing the direct or Iip voke Ieakage; hence, when cigarette drains type of fistula. In such cases, surgica1 are used, the gauze should not project closure is necessary. The iIea1 fistuIas are beyond the end of the Penrose tubing. The more apt to be compIete and are Iess IikeIy tip of the drain may be pIaced near but not to heal spontaneousIy than are those in against the suture Iine. Moreover, when the cecum. Here, the added compIications feasibIe, it is we11 to interpose the omen- of spur formation, herniation, or obstruc- turn between the suture Iine and the drain. tion dista1 to the fistma are mechanica In the forty-nine cases of fistulas foIIow- factors which serve to maintain the fistu- ing appendicitis reported by Lewis and Ious opening and they must be recognized Penick, the opening was in the cecum in and corrected by the proper surgica1

twenty-one, or 72.4 per cent, in the hm procedures. As a rule, in the fistulas asso- in four, or 13.7 per cent, and in the ciated with appendicitis, conservative appendix in a similar number of cases. In treatment shouId be given a prolonged the remainder of their cases, the point of trial before resorting to operative cIosure. communication could not be determined. Even though a surgica1 repair may be In the thirty fistulas associated with necessary at a later date, a successfu1 appendicitis studied by Ransom and CoIIer, resuIt is much more IikeIy to be obtained the opening was in the termina1 iIeum in when the IocaI inffammatory reaction has thirteen, in the cecum in four, in both been given a chance to subside before cecum and iIeum in two, in the sigmoid in operation is attempted. one, and was undetermined in ten cases. REFERENCES The diagnosis of an intestinal fistula I. CUTLER, ELLIOTT C. and SCOTT, W. J. M. Post- ordinariIy is not difficult. In the case of operative Complications. SurgicaI Diagnosis, most ceca1 f%tuIas, the discharge is semi- Graham, Chapt. III, pp. 128. PhiIadeIphia and London, 1930. W. B. Saunders Co. solid and is not especiaIIy irritating to the 2. ALLEN, ARTHUR W. Acute abdominal emergencies. skin. The fistuIas higher in the smaI1 intes- Mtssissippi Doctor, 17 : 304, 1939. tine are associated with an irritating dis- 3. COLLER, FREDERICK A. and POTTER, E. B. The treatment of peritonitis associated with appen- charge and, due to the fluid character of dicitis. J. A. hf. A., 103: 1743, 1934. the contents, considerable quantities of 4. STAFFORD, EDWARD S. and SPRONG, DAVID H., JR. ffuid, eIectroIytes and food substances may The mortaIity from acute appendicitis in the be Iost. OccasionaIIy, it may be diffrcuIt to Johns Hopkins Hospital. J. A. M. A., I 15: 1242, 1940. distinguish between a fecal IistuIa and a 5. BARROW, WOOLFOLK and OCHSNER, ALTON. Treat- colon baciIIus infection of the wound or in a ment of appendica1 peritonitis. J. A. M. A., I 15: 1246, 1940. hematoma. Dixon mentions the impor- 6. HORSLEY, J. SHELTON. Peritonitis. Arch. Surg., 36: tance of the history of the passage of gas 180, 1938. in such cases as indicative of fistuIa and, in 7. HERRICK, F. C. Acute appendicitis with peri- tonitis: treatment and mortality. Surg., Gyner. doubtfu1 cases, suggests the use of a dye Ed Obsl., 65: 68, 1937. such as carmine red by mouth. Roentgen 8. DAVIS, C. R. Critical anaIysis of thirty-five deaths studies foIIowing injection of the fistuIous folIowing appendicitis; when should detayed operation of ruptured appendicitis and peri- opening with some radio-opaque materia1 tonitis be used? Am. J. Surg., 29: 368, 1935. is often of value in Iocahzation. Injection g. OCHSNER,ALTON, GAGE, I. M. and GARSIDE, EARL. in conjunction with a barium often The intra-abdominal postoperative complications of appendicitis. Ann..Surg., 91: 544, rg3o. gives additiona information. IO. HANFORD, JOHN M. The indications for intra- The fistuIas associated with appendicitis peritonea1 drainage in operations for acute NEW SERIESVOL. LVI, No. I Ransom-Appendicitis American Journal of Surgery 117

appendicitis. Surg. C/in. North America, rg: 385, 29. WANGENSTEEN, 0. H. Discussion of paper by ,939. Lehman and Parker. Ann. Surg., 108: 853, 1938. I I. I.OVE, R. .I. M. Prognosis in acute appendicitis. 30. OCHSNER, ALTON, DEBAKEY, MICHAEL and Brit. J. SurP;., 12: 232, 1924. MURRAY, S. Pyogenic abscess of liver, analysis of 12. CCTLEK, CONDICT W., JR. Secondary peritoneal forty-seven cases with review of literature. Am. abscesses following appendicitis. Surg. C/in. J. Surg., 40: zgz, ,918. North America, 10: 423, 1939, 31. KOSTER, HARRY. Thorium dioxide as an aid in the 13. OCHSNER, ALTON and DEBAKEY, MICHAEL. Sub- differential diagnosis of pylephlebitis. &tdiology, phrenic abscess: collective review and analysis 33: 728, 1940. of 3608 collected and personal cases. Internat. 32. SI~~EONE, F. A. and STEWART, JOHN D. Acute Ahst. Surg., 66: 426, 1938. hepatitis, jaundice and abnormal bleeding as 14. F.~xo>, IIENRV II. Logical approach to subphrenic complications of acute appendicitis with perfor- abscess. Am. J. Surg., $4: 114-126, 1941. ation. New England J. M., 223: 632, ,940. I 5. WEL.L~.~~, Jo~~K M. C. and MADDOCK, WALTER G. 33. VANBEUREN, FREDERICK T., JR. Review of acute Subphrenic abscess. Unit). Hosp. Bull., Unio. ileus or a complication of acute appendicitis. .2lich., Ann Arbor, 5: IO, 1939. Surg. C/in. North America, 19: 407, ,939.

16. OWRHOLT, RICHARD H. IntraperitoneaI pressure, 34. WANGENSTEEP~, 0. II. The Therapeutic Problem of Arch. Surg., 22: 691, ,931. Bowel Obstructions: A Physiological and Clin- 17. ~~LNRO, J. C. Lymphatic and hepatic infections ical Consideration. Chap. II, p. 48, Springfield, secondary to appendicitis. Ann. Surg., 42: f&2, Illinois, 1937. CharIes C. Thomas. 19o5. 35. WAI\I(;EUSTEEN,0. I-f. and PAINE, J. R. Treatment 18. BARNARD, II. L. Surgical aspects of subphrenic of acute intestinal obstruction by suction with abscess. Brit. ,l4. J., 1: 371, rgo8. thy duodena1 tube. J. A. M. A., IOI : I $32, 1933. 19. TRUESDALE, PHILEMON E. Origin and course of 36. ORR, T. G. The action of morphine on the small infection in subphrenic abscess. Ann. Surp., 98: intestine and its clinical application in the trrat- 846, ,933. ment of peritonitis and intestinal obstruction. 20. IMARTINET. Des va&tCs anatomiques et d’abcPs Tr. Am. Surg. Ass., $‘: 319, 1933. sous-phrPniqucs. Thesis of Paris, ,898. 37. OctlsXeR, ALTON. MetaInparotom?; functional 21. BARKARD. H. L. SurgicaI aspects of subphrenic ilcus. Surg., Gtfnec. d+ Ohst., 52: 702, 1931. abscess. Brit. M. J., I: 429, ,908. 38. OcttsNER, AI.TON and GAGE, I. ,jl. Adynamic iIcus. 22. OCHSNER, ALTON. Subphrenic abscess. New Orleans Am. J. Surg., 20: 378, 1933. M. P Surg. J., 81: 102, ,928. 39. OCHSNER, ALTON. Postoperative treatment based 23. OCHSNER, ALTON. Surgical treatment of sub- on physiological principles. Sour6. Sure., 4: I)-, phrenic infections. New Orlenns M. c~ Surg. J., 82: 752, rgjt,. 1035. BANKS, B. M. and L. The 24. OCHSNER, AL-ror\. Subphrenic abscess: its diagnosis 4o. FI\;E, J., I~EKMA~SON, treatment of gaseous distention of the intestine and treatment with specia1 reference to the by the inhalation of g5 per cent oxygen. Ann. cxtraperitoneal operation. Int. Clin., 2: 79, ,931. 25. NATHER, I(. and OCHSNER, ALTON. Retroperitoneal Surg., 103: 375, 1936. operation for subphrenic abscess. Surg., G~vnec. qr. RAKSOM, H. K. and COLLER, F. A. Intestinal (Y Ohst., 37: 665, 1923. fist&. J. Michigan State M. Sot., 34: 281, ,035. 26. OCHSKER, A~ror\ and GRAVES, AMOS hl. Subphrenic 42. LEXVIS,DEAN and PE~ICF;, R. M., JR. Fecal listulae. abscess: an analysis of 3372 collected and per- Internal. Clin., I: 111, 1933. sonal cases. Ann. Surg., 98: 961, 1933. 43. MARSHALL, S. F. and LAHEY, 1;. 1~1.The surgical 27. F;\xoN, IIEXRY I-I. Subphrenic abscess. New treatment of abdominal list&c. New Eneland England J. M., 22: 289, 1940. RI. J., 218: 21 I, 1938. 28. LEHMAN, E. P. and PARKER, W. II. The treatment 44. DIXOY, CLALDE F. and DE<.TEK>~A~,JOEI 1.. The of intraprritoneal abscess arising from peri- management of external intcstinnl fist&e. tonitis. Ann. Surg., 108: 833, 1938. J. A. i\;l. i\., I I I : 2095, 1938.