M E C H A N I C A L L E S I O N S OF T t t E A P P E N D I X IN C H I L D R E N

AS A BASIS FOR A P P E N D I C I T I S

PEaCIVAL NICtIOLSON, M.D. ARDMORE, PA.

T HIS is an invest igat ion based on the s tudy of 127 consecutive cases of mechanical lesions affecting the appendix in children exhibi t ing

symptoms not general ly a t t r ibu ted to a dis turbance of this organ, but clearly distinguishable bY clinical and labora tory investigation. These findings were confirmed in all cases by careful s tudy of the gross anatomical changes at operation, as well as by microscopic examina- tion. In these lesions was found a basis for an explanation of a large number of cases of appendicit is in both childhood and adul t life gen- eral ly considered as acute p r imary forms. A diagnosis of mechanical lesions of the appendix was possible at such an ear ly stage that by surgical removal of the causative fac to r the morta l i ty ra te was kep t at a minimum. In this series i t was zero.

I t is also proposed to show tha t by early surgical intervention, not only is mor ta l i ty reduced, but the nutr i t ional development of the chil- dren, by its r e tu rn to the normal, produces ideal weight and de- velopment.

This work on mechanical conditions in and around the alJpendix was suggested by the fai lure of some cases of bad posture in children to improve when abdominal supports were applied, or if they did improve they fai led to maintain their improvement. In a certain number there were associated mild at tacks of abdominal pain; a diagnosis of chronic appendicit is was made; and appendectomy was performed. At opera- tion dist inct mechanical lesions in and around the appendix were found and removed together with the appendix. The symptomat ic relief and the nutr i t ional improvement were so marked and rapid that they led to a very careful survey of similar cases; these af ter appendec- tomy had equally good results. This work clearly demonstrates the value of accurate l abora to ry work, the importance of ve ry careful and detailed histories, and a diagnosis largely by exclusion.

Mechanical conditions involving the appendix have been described by numerous authors under the headings of "ch ron ic appendic i t i s , " and "append ica l s y n d r o m e . " The subject, " ch ron ic appendic i t i s , " has been a controversial one in surgical circles fo r years. ~ y e r s 1 quotes Watkins as reviewing 662 papers up to 1932 and reviews the l i tera ture to September, 1934. In his summary he states: " T h e more

From the Pediatric Service of the ]~ryn 'Mawr Hospital.

647

6 ~ THE JOURNAL OF PEDIATRICS

recent l i terature, especially tha t of the last five years, on chronic ap- pendicitis indicates a growing opinion tha t there is such a malady, tha t it is more prevalent , more dangerous, and more f requent ly over- looked than has been previously taught. Indicat ions are tha t failures of the past have been largely due to a lack of diagnostic thoroughness. Certain medical centers have published statistics showing froln 60 to 90 per cent of the pat ients who had operations for chronic appendicitis were completely relieved by appendectomy alone. Muller recently (1932) has said that a campaign of instruct ion of the public regarding appendicit is is more impor tan t than a campaign against cancer. I t seems fair to say tha t such a campaign should be directed to the lai ty regard ing acute appendicitis, but a like campaign is needed for the profession regard ing chronic appendicit is . '"

F'reed 2 states, " In the United States and Canada twenty-five thou- sand die year ly f rom acute appendicitis, t ha t is one death every twenty-flve minutes, or seventy deaths every day, Sundays and holi- days included, and the mor ta l i ty is on the increase . " In childhood there is an average mor ta l i ty of about 14.5 per cent.

F a r r a states, " I also believe tha t there is such an ent i ty as chronic appendicit is and tha t it applies to children ful ly as often as to adults. '~' Tenny~ is convinced of the importance of a mechanical obstructive condition in and a round the appendix as a p roducer of appendicitis, and he emphasizes reflex constipation and pylorospasm. Wilkie, ~, 6 one of the first to describe acute obstructive appendicitis, lays emphasis on constr ict ion of the appendical lumen, with associated fecal concre- tions, and describes both an acute and a chronic form.

In making a diagnosis of mechanical conditions in and around the appendix, it is first necessary to know the normal, anatomy. The ap- pendix hangs down freely f rom the cecum and has a uniform and patu]ous lumen, and a terminal and limited ar ter ia l blood supply. Any kinking, twisting or constriction of the wall of the appendix, whether produced by Lane ' s bands, Jackson 's membrane, short mesentery, or constr ict ion of the lumen due to contract ing fibrous tissue from a previous inf lammatory reaction, will cause fecal retention, and this in tu rn will produce chronic i r r i ta t ion of the appendix. Through the sympathet ic and vagus nerves, there is an in tercommunicat ion with the stomach, often producing pylorospasm with nausea or vomiting, or with the colon, producing spastic constipation.

When the lumen of the appendix is constricted, fecal material may be forced in f rom the cecum. But since the weaker contract ion of the appendical wall is not able to evacuate completely the contents, a portion remains, and its moisture is absorbed th rough the appendical wall and produces a beginning inspissation which may lead to concretion. I f this change is not severe enough to obstruct the lumen completely,

N I C H O L S O N : 1V[ECHANICAL LESIONS OF APPENDIX 649

there are chronic symptoms, such as pain, spastic constipation, " b i l -

ious a t t a c k s , " vomi t ing , etc. I f the concretion comple te ly obs t ruc ts the lumen, more severe changes may follow, often ending in gangrene. These cases produce, according to Wilkie, 5, 6 90 per cent of the mor- ta l i ty of acute appendicit is . On the other hand, a constr ict ion of the blood supp ly f rom a twist, shor t mesentery, membrane , or bands , causes edema of the wall and predisposes to an in f l ammatory process.

A typ ica l h is tory is tha t of a child who has had shor t a t t acks of recur ren t abdominal pa in for a considerable period, ei ther daily or a t longer intervals. The pain var ies f rom a dull ache, a burn ing sensa- tion, or sense of fullness to one of a sharp s tabbing character . The a t tacks m a y be ve ry fleeting but they have a m a r k e d tendency to recur, and at t imes there is associated nausea or ac tual vomit ing. The r e c u r r e n c e of attacks, in spite of a well-regulated simple diet and good hygiene, is of great significance. Children often stop in their play, t u rn a little white, have a slight generalized abdominal pain, over in an in- stant. These cases are commonly diagnosed as indigestion. The pa in is ve ry l ikely to come on dur ing or f rom one-half to two hours a f t e r a meal, or pains m a y have no relat ion to food intake. Pa in f r equen t ly is increased by exercise, its locat ion is umbil ical or epigas t r ica l at first, bu t la ter m a y become localized in the r igh t iliac fossa. A bowel movement , passage of gas, or vomit ing usual ly gives p r o m p t relief. There are associated poor color, poor muscle tone, poor nutri t ion, and poor posture. Abdomina l suppor t s will often relieve the symptoms for a time, but there is f r equen t ly a recurrence. This fa i lure to pro- duce a pe rmanen t cure wi th abdominal suppor ts is ve ry suggestive. There is poor appet i te , and const ipat ion is the rule. The t empera tu re , pulse, respirat ion, and blood count at this t ime are normal . A careful abdominal examina t ion at the t ime of the a t t ack will reveal in most cases sl ight deep r igh t iliac tenderness with but l i t t le if any muscu la r r igidi ty. I f a review of the fami ly h is tory reveals appendici t is in the near relat ives, it is ve ry suggestive, as heredi ty seems to p lay an im- po r t an t p a r t ; i n this series the rate was 63 per cent. The phys ic ian should inquire as to any py lo rospasm in infancy and any causeless at- tack Of vomit ing or cyclic vomit ing, as in our 127 cases 66 per cent had vomi t ing and 6 per cent cyc:ic vomiting.

La t e r pain m a y move over to the lower r ight quadrant . A white blood count with careful s tudy of the neutrophiles, including a nuclear shift, then shows slight i r r i ta t ive changes but not much elevation of the total count. As the case becomes more acute, there m a y be a slight t empera tu re e levat ion dur ing the at tacks. At opera t ion bands, ad- hesions, Jackson"s membrane , a short mesentery, or s t r ic ture of the appendix with fecal concretions is found. The appendical lumen usually shows cystic di latat ion and some a t rophy of the mucous mere-

6 5 0 THE JOURNAL OF PEDIATRICS

brane with a possible old fibrosis of the walls f rom a previously healed

acute a t tack . I f operat ion is pe r fo rmed ve ry ear ly in the course of

the infection, no appendieal lesion m a y be found.

Ano the r f requent type is tha t found in a child who has been iu ap-

pa ren t ly good health, but usual ly whose nu t r i t ion is poor, as shown by

a searching history. I~e goes to bed to awake several hours la ter with

sharp abdominal pa in whieh causes him to double up. Tile pa in is

soon relieved, and he sleeps again only to awaken a second t ime with

a r e tu rn of colic, and he f requent ly vomits. At first the pa in is in the

umbil ical region, acute and spasmodic; l a te r i t becomes less acute but more continuous, and becomes localized in the r igh t lower quadrant .

The tempera ture , the pulse, and the resp i ra t ion are normal , but there

is a lways a s l ight ly anxious expression. These a t t acks of appendieal eolic m a y have numerous remissions. E x a m i n a t i o n dur ing a t tacks

shows deep r ight iliae tenderness. A p r o m p t operat ion is indieated; at opera t ion the append ix presents some f o r m of constr ic t ion and con-

ta ins inspissated fecal mater ia l or a concret ion and often gangrene.

There is also a type of mild acute appendicit is , p robab ly embolic, secondary to an infect ion f rom sinusitis, tonsillitis, etc. The pa t ien t

has malaise and nausea, a fu r red tongue, loss of appeti te , and con- s t ipa t ion with a ve ry sl ight tempera ture . There is vague abdominal

pa in at the umbil icus which la te r becomes more or less localized in the r igh t side. The pa t i en t m a y be in bed a day or two, at the end of which t ime the symptoms gradua l ly clear up. Deep iliac tenderness can be obtained, and if an operat ion is pe r fo rmed , edema of the ap- pendical wall is found. I t is often these over looked a t tacks which cause in f lammatory react ion with subsequent flbrotie s t r ic ture of the appendix.

There are numerous other combinat ions of symptoms nei ther so definite nor so suggest ive of chronic appendicit is , but equally impor- t an t to the child. A child who on automobile t r ips has nausea or actively vomits, or who has had periodic at tacks of vomiting, either repea ted mild a t t acks often in the morn ing before b r e a k f a s t or severe ones wi th associated acidosis, p robab ly has chronic appendicitis. He may, however, never have had any abdominal pain. A white blood count wi th a nuclear shif t m a y show sl ight i r r i ta t ive changes, as in- crease in rod nuelears, in addi t ion to changes suggest ing a more chronic inflammation, as ]ymphoeytos is and monoeytosis . An exami- na t ion of the abdomen at the time of a vomit ing a t t ack f requen t ly dis- covers deep iliac tenderness and less of ten r igh t rectus r igidi ty. These pa t ien ts are t r ea ted as a rule for an imbalance of the sympa- thet ic nervous sys tem causing reflex vomi t ing and spast iei ty of the colon~ resul t ing in colicky pains and constipation. A roentgen ray

N I CH O LSO N : MECHANICAL LESIONS OF APPENDIX 651

s tudy of the gas t ro in tes t ina l t r a c t may occasionally disclose a par- t ia l ly filling appendix which does not empty in the normal t ime (only one case in this series), but, as a rule, roentgen rays are not conclusive except as evidence of spast ie i ty of the colon. I~oentgen ray examina- t ions were not used in this series on account of the expense and the fac t tha t the diagnosis could be made wi thout thei r aid. I t was also fel t tha t the ba r ium and b i smuth re ta ined would complicate convales- cence following operation. I t is necessary to proceed with ex t reme

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E

T-

FAMILY HISTORY OF APPEPIDICIT 15

NERVOUSME,% IRRITABILITY POOR SCHOOL WORK FAILURE TO GAIN POOR PO5TURE CAR 51CKNE35 PYLORIC SPASH roll

POOR APPETITE I CONSTIPATION ABDONINAL PAIN5 NAUSEA OR VONITING

DIARRHEA LA~(ATIVE,5 ,SIPIUSITI5 FULLfl[SS �9 ANOREXIA ~ I COMSTIPATION

DIARRHEA �9 ABDOMINAL P~II'I5 51NUSITI3 I N ~ 5 ~ OR ~MITING ABDOI"IINAL TEPID[RI1 [ 55 ,qDDOPIINAL RIGIDITY TEHPERATURE ELEVATION I

Chart l.--Symptomatology.

~ 0 10 zo 30 40 50 60 70 80 90 100

caut ion and observe these pat ients for some t ime and to rule out any involvement of the geni tour inary tract, by urinalysis and roentgen- ograms if necessary, but when by a process of elimination focal infections are excluded, one is justified in mak ing a diagnosis of mechanical lesions in or a round the appendix. Diagnoses are l a rge ly based on a h i s to ry of long-cont inued symptoms and by el iminat ion r a the r than b y physical findings.

There is another group of children with definite symptoms of chronic appendic i t i s ; in these the blood count usual ly shows an eosinophilia,

652 TI~E JOURNAL OF PEDIATRICS

with an average of 4 per cent. Most of these pa t ien ts in our series had sea tworms in the appendix and were complete ly rel ieved by ap- pendectomy. This condition was first recognized in 1899 by Still 7 and has been la te ly reviewed by Marga re t Warwick . s

Once a diagnosis is established, an immedia te appendec tomy is un-

doubtedly the only t rea tment . In cases in which a diagnosis of chronic or mild acute appendici t is is associated with a sinusitis or other upper resp i ra to ry infection, one shou ld operate at once. I t used

,l ~= E .

i

~6 ,b io 3o 40 5o 6o 7o-~ ~o 7o0 i"lO CHAIIGE5

SUB-ACUTE ACUTE CHRONIC JACKSOrI$ MEMBRANE ADHESIONS SHORT FIESENTERY OTItER AI1ATOMI~L ABIORI1/ClIIE5 KIIiK[D APPFMDIX PERITONITIS I 1ECHAI'IICAL OBSTRUCTIOM

�9 I'10 LESIOI1S m CHROMIC IilRAMNATIOM SUB-ACUTE IMFUINB~IOrl �9 ACUIT. IflfI.AMM~TIOM m

DICTION

OILCULI I~I~ISITE3

rlOLESIOrI$ CrtRONIC I,SU&gICUTE ~CUTE DIL~TION

7 0 3P. 5 8 13 20 34 27

IO, ~3 II I,.~ 17 IO, 33 8 g 7

A P P E H D I X uJ NO CflI~IIGE

0. ~CUTE.

C h a r t 2---:Blood p i c t u r e and pa tho log ic f indings.

to be our custom to delay operat ion until the infect ion cleared up, but

we found that severi ty of the appendical condition is gTeatly increased, and there is grave danger of a gangrenous appendix and peritonitis if operation is delayed. By use of t r ibrom-ethanol (aver t in) and the post- operative use of 10 per cent carbon dioxide and 90 per cent oxygen we have had un i formly good results.

I , only one of our series of 127 cases was it necessary to use drain- a g e . Tha t pa t ien t was first seen two days a f te r the onset of acute symptoms, Recovery was complete .in th i r ty-nine days.

N I C H O L S O N : :MECHANICAL LESIONS OF A P P E N D I X 653

The most constant symptoms in our cases were attacks of abdominal pain, generalized at first, later sometimes localized with associated nausea or vomiting. The most common physical finding was deep ten- derness in the right iliac fossa.

Charts 1, 2, and 3 give the frequency of occurrence of the various symptoms, findings at operation, pathologic conditions, and the results.

The pathologist in cases os chronic appendicitis must examine the appendix not only for signs os chronic fibrosis and acute inflammatory changes but also for evidence of cystic dilatation as is shown in micro- scopic section by flattening out os the rugae and also by atrophic changes in the mucosa.

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u~

UNEVErnrUL RCCOVrRY STITCH ABSCE55 �9 MELECT~515 I

MERu ~- i I/"IPROVED IRRITABIUTY ~ l'loT IMP I

SCI-IO01:WORK i IMPROVED t i'IOT IMP. �9

GAIM IM WEIGHT i II'IPROVED 'MOT IMP �9 dMPROVED

CAR 51C~NE55 INOT IMP I

IIMPROVED APPETITE LMOT IMP I

IIMPROVED CONSTIPATION LNOT IMR I

ABDOMII'i~L iI MPROVED PA~r~5 ~rlOT iMP. 0

IIMPROVED II VOMITING el'lOT IMR 0

iI P'IPROVED DI~RRI'IE~ /PIOT IMP 0

C h a r t 3 . - - P o s t o p e r a t i v e course a n d resu l t s .

In an analysis of the Bryn Mawr Hospital pathologic records of acute appendicitis in adults, approximately 95 per cent showed evi- dences of preceding fecal retention and cystic dilatation.

CONCLUSIONS

1. In 127 consecutive cases of mechanical lesions affecting the ap- pendix in childhood, the symptoms usually began at an early age in mild form and recurred over a long period, the most constant being recurring abdominal pain, frequently associated with vomiting and deep right iliac tenderness.

654 THE JOURNAL OF PEDIATRICS

2. I n a d d i t i o n to c o m p l e t e r e c o v e r y a n d r e l i e f f r o m s y m p t o m s in a l l

cases f o l l o w i n g a p p e n d e c t o m y , t he c h i l d r e n s h o w e d a v e r y n o t a b l e in-

c rease in we igh t .

3. The e x t r i n s i c causes of o b s t r u c t i o n of the a p p e n d i x p r e d o m i -

n a t e d , o f t en l e a d i n g to o b l i t e r a t i o n of t h e l u m e n a n d r e t e n t i o n of feca l

m a t e r i a l .

4. A p p r o x i m a t e l y 95 p e r cen t of a d u l t a p p e n d i c e s r e m o v e d a t the

B r y n M a w r H o s p i t a l s h o w e d ev idence of o b l i t e r a t i o n of the l u m e n

w i t h f eca l r e t e n t i o n p r e c e d i n g the t e r m i n a l i n f l a m m a t o r y a t t a c k .

5. B y a c a r e f u l d i a g n o s i s in c h i l d h o o d a n d e a r l y ope ra t i on , n u t r i -

t i on a n d d e v e l o p m e n t cou ld be m a d e n o r m a l a t t h i s age pe r iod , and

m o r t a l i t y could be m i n i m i z e d a t al l ages .

REFERENCES

1. Myers, B .L . : J. Missouri M. A. 31: 363, 1934. 2. Freed, C.E. : 1Jenasylvanla IV[. J. 39: 5, 1935. 3. l~arr, C.E. : Surg. Clin. North America (April), 1935. 4. Tenny, Charles F. : New York State J. N~ed. 35: 977, 1935. 5. Wilkie, D. P .D. : Brit. M. J. 1: 253, 1931. 6. Wilkie, D. P .D . : Canad. M. A. J. 22: 314, 1930. 7. Still, George I%: Common Disorders and Diseases of Childhood, ed. 4, Oxford

University Press, page 322. 8. Warwick, Margaret: Am. J. Clin. Path. 5: 238, 1935.