Acute appendicitis in chronically ill geriatric patients

Abstract

Twenty-one chronically ill substandard risk patients between the ages of sixty and ninety who had acute appendicitis with or without abscess or peritonitis are discussed. They cover a period between 1939 and 1951. The disease is infrequent in geriatric patients and usually serious. Atypical clinical syndromes, difficulty in diagnosis, delayed operation, catharsis and accompanying degenerative disease all contribute to a high mortality. Our mortality rate is 23.8 per cent. Mortality statistics from other sources are also high. Peritonitis, pneumonia, cardiac failure and thrombosis have been among the leading causes of death in several autopsies. Suggestions are made to help reduce mortalities. The pathology is discussed. Microscopic studies were made of the appendices in the acute conditions and of others removed in autopsies on patients sixty and over who died of causes other than acute appendicitis. The observations suggested that early massive gangrene might result from diminution or absence of lymphoid follicles in the wall of the appendix, sclerosis of the vessels supplying it, obstruction in its lumen and previous damage to the appendix by inflammation. It is significant that all the eleven patients who had acute appendicitis without perforation survived after appendectomy. We do not subscribe to the so-called conservative therapy as a routine in which the appendix is not removed or in which abscesses or peritonitis are not drained. Antibiotic therapy has supplemental rather than substitutional value for surgery. Appendectomy is indicated except in those cases in which technical difficulty would prolong the operative time to such an extent that the hazard to life would be markedly increased or when additional trauma would be instrumental in further spread of infection. Generally, the McBurney incision is the most preferable.