Edmund Owen

“ To carry about a diseased appendix is to run the constant risk of being laid up at a time most inconvenient, as when travelling or when staying in some place where skilled assistance is far distant or absolutely unobtainable. But having made up his mind that the appendix had better be removed, the patient can choose time, place and surgeon, and, having undergone a week’s careful training for the ordeal, can safely count on being back at work again in a month or six weeks’ time. ”

“ Nature is marvellously clever in some of these cases in shutting off the area of the disease by glueing together the neighbouring coils of intestine, the limited local peritonitis causing the tissues to build themselves into a wall which securely shuts in the abscess cavity. But in other cases she seems helpless, no barrier being formed for limiting the area of disturbance. In such a case it is inevitable that disappointment must result from the surgeon delaying operation in the hope that delimitation might take place. ”

“ The most serious cases are those in which the aspect, the pulse, and the temperature of the patient fail to give warning of a very advanced state of disease. Every surgeon of experience has met with cases in which, though there is nothing pointing to the fact that the patient is on the brink of a disaster, the operation has shown that the appendix is mortified, and that it is surrounded with abundant foul matter. ”

“ In a less severe attack, under the influence of rest, starvation and fomentation, and in cases of chronic and of relapsing disease, the surgeon may watch and wait and choose his own time for operating. But when the symptoms are steadily increasing in severity he should urge an immediate incision. When, as often happens, the inflammation begins suddenly and severely, and, under the influence of treatment, steadily quiets down, the surgeon does well to delay operation. ”

“ But in those aneurysms which are fusiform dilatations of the vessel there is but slight chance of such cure, for the blood sweeps evenly through it without staying to deposit clot or laminated fibrine. ”

“ The man who has chronic inflammation of a large artery, the result, for instance, of gout, arduous, straining work, or kidney-disease, and whose artery yields under cardiac pressure, has a spontaneous aneurysm; the barman or window-cleaner who has cut his radial artery, the soldier whose brachial or femoral artery has been bruised by a rifle bullet or grazed by a bayonet, and the boy whose naked foot is pierced by a sharp nail, are apt to be the subjects of traumatic aneurysm. ”

“ If, in a case of appendicitis, for one reason or another operation is to be delayed, what treatment should be resorted to? The patient should be put to bed with his knees resting over a pillow, and a large fomentation under oil silk should be laid over the lower part of the abdomen. No food should be given beyond an occasional sip of hot water. ”

“ The most satisfactory course which it can take is through the wall of the abdomen and out above the right groin. As it is making its way in this direction the skin over that part becomes red, swollen, hot and tender, and the tissues between it and the skin become swollen and brawny. Rarely is fluctuation to be made out until the pus has worked its way close to the surface. ”

“ And until his vulnerable appendix has been removed he is never safe.
In the chronic form of the disease though the patient is never desperately ill he is never quite well. He has pains and discomfort in the abdomen, with slight tenderness and nausea, with “indigestion,” as he may call it. And as one can never tell when the smouldering inflammation may break out into conflagration, he is well advised to submit himself to operation without further delay. ”

“ Later, the skin of the lower part of the right side of the abdomen may be flushed or reddened.
This clinical picture leaves no room for doubt. The boy has an attack of acute septic inflammation of his appendix. Let it be that the symptoms have come on quickly, and that the affection is not more than ten or twelve hours old; no one can tell precisely what course the disease is going to run. It may be that with rest in bed, constant fomentations, and absolute starvation, the inflammation will subside ”

“ The boy has had, may be, occasional attacks of “indigestion” which have duly passed away under the influence of aperient medicines, and, being heated at play, he has sat down upon the cold ground. Or he has got wet through or over-tired during a long walk or ride. ”