Islam in Malaysia: An Entwined History

Khairudin Aljunied
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i

Islam in Malaysia
ii

RELIGION AND GLOBAL POLITICS

Series Editor

John L. Esposito
University Professor and Director
Prince Alwaleed Bin Talal Center for Muslim-​Christian Understanding
Georgetown University

Islamic Leviathan The Headscarf Controversy

Islam and the Making of State Power Secularism and Freedom of Religion
Seyyed Vali Reza Nasr Hilal Elver
Rachid Ghannouchi The House of Service
A Democrat Within Islamism The Gülen Movement and Islam’s
Azzam S. Tamimi Third Way
David Tittensor
Balkan Idols
Religion and Nationalism in Mapping The Legal Boundaries of
Yugoslav States Belonging
Vjekoslav Perica Religion and Multiculturalism from Israel
to Canada
Islamic Political Identity in Turkey
Edited by René Provost
M. Hakan Yavuz
Religious Secularity
Religion and Politics in Post-​Communist
A Theological Challenge to the
Romania
Islamic State
Lavinia Stan and Lucian Turcescu
Naser Ghobadzadeh
Piety and Politics
The Middle Path of Moderation in Islam
Islamism in Contemporary Malaysia
The Qur’ānic Principle of Wasaṭiyyah
Joseph Chinyong Liow
Mohammad Hashim Kamali
Terror in The Land of the Holy Spirit
Containing Balkan Nationalism
Guatemala under General Efrain Rios
Imperial Russia and Ottoman Christians
Montt, 1982–​1983
(1856–​1914)
Virginia Garrard-​Burnett
Denis Vovchenko
In the House of War
Inside the Muslim Brotherhood
Dutch Islam Observed
Religion, Identity, and Politics
Sam Cherribi
Khalil al-​Anani
Being Young and Muslim
Politicizing Islam
New Cultural Politics in the Global South
The Islamic Revival in France and India
and North
Z. Fareen Parvez
Asef Bayat and Linda Herrera
Soviet and Muslim
Church, State, and Democracy In
The Institutionalization of Islam in
Expanding Europe
Central Asia
Lavinia Stan and Lucian Turcescu
Eren Tasar
iii

Islam in Malaysia
An Entwined History
zz
KHAIRUDIN ALJUNIED
Georgetown University
National University of Singapore

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2019

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Aljunied, Syed Muhd. Khairudin, 1976– author.
Title: Islam in Malaysia: an entwined history / ​
Khairudin Aljunied.
Description: New York, NY : Oxford University Press, 2019. |
Series: Religion and global politics | Includes bibliographical references and index.
Identifiers: LCCN 2019009759 (print) | LCCN 2019013515 (ebook) |
ISBN 9780190925208 (updf ) | ISBN 9780190925215 (epub) |
ISBN 9780190925192 (hardback) | ISBN 9780190925222 (online content)
Subjects: LCSH: Islam—Malaysia—History. | BISAC: RELIGION / Islam /
General. | HISTORY / Asia / General. | RELIGION / Religion, Politics & State.
Classification: LCC BP63. M27 (ebook) | LCC BP63. M27 A445 2019 (print) |
DDC 297.09595—dc23
LC record available at https://lccn.loc.gov/2019009759

1 3 5 7 9 8 6 4 2

Printed by Sheridan Books, Inc., United States of America

v

Contents

List of Figures vii

Acknowledgments ix
List of Abbreviations xi
Glossary xv

Introduction  1

PART I : Gradualist Islamization

1. Infusing Islam in Connected Societies  21

2. Sufis, Sufism, and Conversion Narratives  40

PART II : Populist Islamization

3. Kerajaan Proselytism  61

4. Women and Other Islamizers  85

PART III : Reformist Islamization

5. Islam and Colonialism  107

6. Repertoires of Muslim Resistance  130

vi

vi Contents

PART IV: Triumphalist Islamization

7. Constructing a Malay-​Triumphalist Islam  161

8. Nationalizing Islam, Islamizing the Nation  185

Notes 215
Bibliography 263
Index 305
vi

Figures

I.1. Masjid Negara, Kuala Lumpur 2

Source: https://commons.wikimedia.org/wiki/File:
Masjid_ Negara_ KL.JPG
1.1. Bujang Valley Candi 26
Source: https://commons.wikimedia.org/wiki/File:
006_Bujang_Valley_Candi.jpg
2.1. The Terengganu Stone 44
Source: https://commons.wikimedia.org/wiki/File:
Pr_Terengganu_A.jpg
3.1. Coins from the Kerajaan 66
Source: See Colin H. Dakers, “The Malay Coins of
Malacca,” Journal of the Malaysian Branch of the Royal
Asiatic Society 17, 1 (1939): 3
4.1. Disembarkation point of Cheng Ho in 1405 97
Source: https://commons.wikimedia.org/wiki/
File:Disembarkation_point_of_Admiral_Zheng_
He_in_1405.jpg
5.1. Sultans at First Malayan Durbar 112
Source: https://commons.wikimedia.org/ wiki/
File:Sultans_at_the_first_Malayan_Durbar.jpg
6.1. Mat Salleh Memorial in Tambunan, Sabah 136
Source: https://commons.wikimedia.org/wiki/
File:Tambunan_Mat-Salleh-Memorial02.jpg
vi

viii List of Figures

7.1. The first Prime Minister of Malaysia,

Tunku Abdul Rahman 165
Source: https://commons.wikimedia.org/wiki/File:
Aankomst_van_premier_van_Malakka_Abdul_
Rahman,_Bestanddeelnr_911-2803.jpg
8.1. Bersih 4.0 Rally at Pasar Seni, Kuala Lumpur 208
Source: https://commons.wikimedia.org/wiki/
File:Bersih_4.0_rally_at_Pasar_Seni_Day_1.jpg
ix

Acknowledgments

Far too many promises have been broken and mountains of debt accumulated
in the process of writing of this book. Three years ago I assured my wife that
I would be taking a long break upon the completion of a monograph. Two books
later, I am still comforting her during late-​night conversations that the much-​
awaited pause from writing is just around the corner. I am left with one last ex-
cuse: this book and those that came before it were written with her in mind. So
the first note of thanks (and love) must therefore go to Marlina, who stood by me
in difficult times, in moments of joy and periods of sadness. Never once had she
complained about my demanding schedule and time spent away from her and
my six fast-​growing children: Inshirah, Fatihah, Yusuf, Muhammad, Yasin, and
Furqan. This book is dedicated to her.
A host of institutions and generous individuals have made this book possible.
The National University of Singapore granted me leave from teaching. Jonathan
Brown, an amazing scholar and friend, arranged my appointment as the Malaysia
Chair of Islam in Southeast Asia at Georgetown University’s Prince Alwaleed
Bin Talal Center of Muslim-​Christian Understanding (ACMCU). The time in
ACMCU was memorable. John Esposito left the most lasting impression on me,
urging to get the book done while reminding me to spare some time to have fun.
I benefited so much from conversations with Tamara Sonn, Yvonne Haddad, and
John Voll.
While based at ACMCU, I traveled and shared aspects of the ideas found
in this book at various seminars organized at Duke, Hofstra, Stockholm, Lund,
and Leiden universities and the University of Sains Islam Malaysia. I must thank
Bruce Lawrence, Timothy Daniels, Johan Lindquist, Ben Arps, and Mahazan
Abdul Mutalib for arranging these productive sessions with staff and students.
Professor Osman Bakar provided many useful pointers and publications that
shaped the writing of this book.
Beyond work, I am grateful to members of the Herndon study circle, who
kept me happy and sane. Asmar, Gunawan, Sonny, Syafarin, Sandy, Umar, Hafidz,
x

x Acknowledgments

Oscar, Reza, Ino, and Irwan were among the best of friends, always there to
help and never ceasing to offer encouragement. Derek Heng, Anthony Milner,
Shamsul A.B., Wan Zawawi, Raj Brown, Syed Faizal, Kamaludeen, Mahazan,
Maszlee, Hafiz, Shuaib, Sujuandy, Shaharudin, Faizal, Iqbal, Sven, Emin, Daman,
Rosdi, Irwin, and Ermin helped in countless ways.
The two anonymous reviewers improved my thinking and writing of this
book. My editor at Oxford University Press, Cynthia Read, and her team guided
me from the conceptualization all the way through publication. They have cer-
tainly made it better than I could have done on my own.
My parents have been supportive of my work throughout, and this book bears
the traces of my love and gratefulness to them. May Allah reward them abun-
dantly for all their sacrifices and prayers.
xi

Abbreviations

ABIM Angkatan Belia Malaysia

ADIL Pergerakan Keadilan Sosial
API Angkatan Pemuda Insaf
ASNB Amanah Saham Nasional Berhad
ASWAJA Pertubuhan Ahli Sunnah Wal Jamaah Malaysia
AWAS Angkatan Wanita Sedar
BA Barisan Alternatif
BARJASA Barisan Anak Jati Sarawak
BATAS Barisan Tani SeMalaya
BIMB Bank Islam Malaysia Berhad
BKM Barisan Kebangsaan Melayu
BMA British Military Administration
BN Barisan Nasional
BPS Barisan Pemuda Sarawak
CPIRUHAA Committee for the Promotion of Inter-​Religious
Understanding and Harmony Among Adherents
DAP Democratic Action Party
FMS Federated Malay States
GAGASAN Gagasan Demokrasi Rakyat
GEPIMA Malaysian Indian Muslim Youth Movement
GERAK Gerakan Keadilan Rakyat Malaysia
GERAM Gerakan Angkatan Muda
GDP Gross Domestic Product
HIKMAH Harakah Islamiah
HM Hizbul Muslimin
IDB Islamic Development Bank
ICA Industrial Co-​ordination Act
IAIS International Institute of Advanced Studies
IIFSO International Islamic Federation of Student
Organisation
IIIT International Institute of Islamic Thought
xi

xii List of Abbreviations

IKIM Institut Kefahaman Islam Malaysia

IMF International Monetary Fund
IMP Independence of Malaya Party
INDAH The Institut Dakwah dan Latihan Islam
IOK Islamization of Knowledge
IRF Islamic Renaissance Front
IRC Islamic Representative Council
ISMA Ikatan Muslimin Malaysia
ISTAC International Institute of Islamic Thought
JAKIM Jabatan Kemajuan Islam Malaysia
JAWI Jabatan Agama Wilayah Persekutuan
JIM Pertubuhan Jamaah Islah Malaysia
JKSM Jabatan Kehakiman Syariah Malaysia
KJM Khairat Jumaat Muslimin
KMM Kesatuan Melayu Muda
KMS Kesatuan Melayu Singapura
KRIS Kekuatan Rakyat Istimewa
LEPIR Lembaga Pendidikan Rakyat
LKPI Lembaga Kebajikan Perempuan Islam
LUTH Lembaga Urusan Tabung Haji
MACMA Malaysian Chinese Muslim Association
MAPEN Majlis Perundingan Negara
MATA Majlis Agama Tertinggi Se-​Malaya
MCA Malayan Chinese Association
MCP Malayan Communist Party
MEC Malay Education Council
MIC Malayan Indian Congress
MIG Medical Interest Group
MNC Multinational companies
MPAJA Malayan Peoples’ Anti-​Japanese Army
MPM Majlis Pelajaran Melayu
MSM Majlis Syura Muslimun
NEP New Economic Policy
NGOs Non-​governmental organizations
NOC National Operations Council
OIC Organization of the Islamic Conference
OWC Obedient Wives Club
PLO Palestinian Liberation Organization
PANAS Parti Negara Sarawak
PAP People’s Action Party
PAPAS or PESAKA Parti Pesaka Anak Sarawak
PAS Parti Islam Semalaysia
xi

List of Abbreviations xiii

PASPAM Persaudaraan Sahabat Pena Malaya

PBB Parti Pesaka Bumiputera Bersatu
Pemenang Persatuan Melayu Pulau Pinang
PERAM Pemuda Radikal Melayu
PERKASA Pertubuhan Pribumi Perkasa
PERPEMAS Pusat Perekonomian Melayu Se-​Malaya
PERKIM Pertubuhan Kebajikan Islam Malaysia
PETA Pembela Tanahair
PH Pakatan Harapan
PIM Persatuan Ikhwan Muslimin
PIP Persatuan Islam Putatan
PIS Persatuan Islam Sabah
PIT Persatuan Islam Tawau
PKM Parti Komunis Malaya
PKMM Persatuan Kebangsaan Melayu Malaya
PKPIM Persatuan Kebangsaan Pelajar Islam Malaysia
PKR Parti Keadilan Rakyat
PMIP Pan-​Malayan Islamic Party
PMSP Persatuan Melayu Seberang Perai
PNB Permodalan Nasional Berhad
PPBM Parti Pribumi Bersatu Malaysia
PPI Pusat Penyelidikan Islam
PPP People’s Progressive Party
PR Pakatan Rakyat
PRB Parti Rakyat Brunei
PRM Parti Rakyat Malaya
PUTERA Pusat Tenaga Rakyat
PUTERA-​AMCJA Pusat Tenaga Rakyat–​All-​Malaya Council of
Joint Action
SAN Sekolah Agama Negeri
SANAP Sabah National Party
SAR Sekolah Agama Sakyat
SNAP Sarawak National Party
SITC Sultan Idris Training College
SIS Sisters in Islam
SS Straits Settlements
SUPP Sarawak United Peoples’ Party
UMNO United Malays Nationalist Organisation
UMS Unfederated Malay States
UNKO United National Kadazan Organization
USIA United Sabah Islamic Association
USNO United Sabah National Organization
xvi

xiv List of Abbreviations

UCSTA United Chinese School Teachers’ Association

WADAH Wadah Pencerdasan Umat
WAMY World Assembly of Muslim Youth
YADIM Yayasan Dakwah Islamiah Malaysia
YMU Young Muslim Union
YPB Yayasan Pelaburan Bumiputera
xv

Glossary

adat customs
akal reason
asabiyyah group feeling
bai’ah loyalty
bangsa race
bid’ah innovations
da’wah Muslim missionary activity
datus noblemen
derhaka treason
dhimmis non-​Muslim minorities
Eidul Fitri celebration of the conclusion of the fasting month
fatwa religious edict
fiqh jurisprudence
hadith Prophetic sayings
hajj pilgrimage to Makkah
halal permissible
halaqah study circles
haram impermissible
hijab Muslim headscarf
hudud Islamic criminal law
ijtihad independent reasoning
imam prayer leaders
islah renewing and reforming
jihad struggle
jizya poll tax
kafir unbelievers
khalwat close proximity between unmarried couples suspected of engaging in
immoral acts
xvi

xvi Glossary

kerajaan Malay kingdoms

keramat miracles
khurafat animistic superstition
khutbahs sermons
madrasahs Islamic schools
maharaja great ruler
mandalas circle of kings
markaz center
maulid celebration of the birthday of the Prophet
muftis expounder of Islamic laws
murshid spiritual guide
nama titles
niqab face veils
penghulu village chief
perang sabil holy war
pondok village boarding school
qadi judge
qaris persons who recite the Qur’an
rajas kings
shahid martyr
shari’a Islamic ethical and religious code
shuyukh eminent scholars
Sunnah Prophetic tradition
surau prayer houses
syahbandar harbormaster
syair rhythmic four-​line stanzas
rakyat masses
ta’awun mutual assistance
tajdid renewal
tariqahs Sufi brotherhoods
taqdir fate
taqlid blind imitation
tarbiyyah education
titah commands
ukhuwwah brotherhood
ulama scholars
ummah global Muslim community
usrah family
wali saints
waqf Muslim endowment
warath al-​anbiya’ inheritors of the Prophet
wasatiyyah moderation
xvi

Glossary xvii

zakat Islamic tithe

zikr remembrance of God
zillullah fil-​alam God’s shadow in the world
zina adultery
xvi
1

Introduction

In late April 2014, Barack Obama made a historic diplomatic trip to

Malaysia, marking the first time in fifty years since an American president last
visited what is regarded by Muslims globally as a leading Islamic country.1 That
Obama was the first African American president whose Arabic middle name is
Hussein added to the euphoria among many Malaysian Muslims about his two-​
day stay in a country the president knew well as a child growing up in neighboring
Indonesia. Obama’s visit was significant in other ways. He spent time touring and
paying tribute to one of the largest Muslim sacred sites in Kuala Lumpur, the
Masjid Negara (National Mosque; Figure I.1). “There can be no better way for
Obama to honour Islam than by visiting Masjid Negara,” said the religious ad-
viser to the prime minister, Tan Sri Dr Abdullah Md Zin. “It will be interesting to
know what he has to say about the mosque and Islam.”2
Obama was indeed visibly impressed with the stunning architecture and
splendor of the mosque, which, to him, reflected the cosmopolitan outlook
of Islam in Malaysia. But he had something equally pertinent to say about the
Muslim-​dominated nation. During a town hall meeting with youth activists on
the same day, Obama addressed what he felt was Malaysia’s enduring strength and
greatest challenge that mirrored the ongoing struggles in his home country: rela-
tions between people of different ethnic backgrounds.

Here in Malaysia, this is a majority Muslim country. But then, there are
times where those who are non-​Muslims find themselves perhaps being dis-
advantaged or experiencing hostility. In the United States, obviously his-
torically the biggest conflicts arose around race. And we had to fight a civil
war and we had to have a civil rights movement over the course of genera-
tions until I could stand before you as a President of African descent. But of
course, the job is not done. There is still discrimination and prejudice and
ethnic conflict inside the United States that we have to be vigilant against.
Another random document with
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distended almost to its bursting point still free or but slightly attached
by exudate. In the milder cases there may be found strictures
indicating the site of previous lesions. Again, aside from pus, there
may be more or less fluid or semisolid fecal matter or dense
concretions, in addition to the possible foreign bodies whose
presence has been elsewhere considered. In the more subacute or
chronic forms there will be found relics of previous rather than active
expressions of present trouble, such as strictures, thickenings,
contortions, old adhesions, sometimes quite dense, and contained
concretions, or other foreign bodies, or one may find appendices
shrivelled up or more or less obliterated (appendicitis obliterans).
The role of the omentum has elsewhere been mentioned, but must
be alluded to again at this point, since it participates more or less in
almost every case of acute appendicitis. The moment the appendix
is acutely inflamed the omentum tends to shift itself over toward it
and finally around it, and it is not uncommon to find a gangrenous
appendix wrapped in a roll of this kindly disposed fatty apron. In fact
this may constitute the tumor which may have been already
discovered and found to be fixed or movable. The inner surface at
least of the omentum thus applied will nearly always have sacrificed
itself and one has need usually to remove a considerable area of
gangrenous omentum, as well as the appendix itself, feeling as he
does it that he is necessarily sacrificing the best friend that the
incriminated appendix has had.
Aside from what may concern the appendix itself the two most
serious complicating local conditions are abscess and gangrene with
perforation. Abscess is not necessarily the result of perforation, at
least at first, but may be due to infection by continuity, the sequence
of events being acute appendicitis, with exudation, fixation, and
adhesion of surrounding tissues, followed by pus formation, perhaps
first within the appendix and then perforating, or perhaps having its
origin in the infected exudate exterior to it. So long as this process is
localized by a protective barrier of surrounding lymph, with intestinal
adhesions and the assistance of the omentum, there is to be dealt
with a more or less complicated peri-appendicular abscess, such as
in the past was frequently seen and spoken of as perityphlitic.
Concerning the frequency of perityphlitic abscess in days gone by
the literature of the previous century will afford ample illustration, but
in spite of the surgical acumen and advice of Willard Parker, who
taught the profession how to deal with it, its proper explanation did
not come until the researches of Fitz, alluded to at the beginning of
this chapter. Even now it is perhaps not quite correct to say that
every typhlitic abscess, i. e., every collection of pus around the
typhlon or head of the large intestine, is of appendicular origin, for
the tendency has been to forget the possibility of phlegmonous
cellulitis about any part of the bowel without reference to the
appendix.
Such a peri-appendicular abscess may be small, containing but a
few drops of pus, or extensive, even to the degree of holding a pint
or more. The pus is usually offensive and sometimes one will find
floating in it shreds of tissue, or even a completely separated and
sloughed-off gangrenous appendix. According to the original location
of the appendix, and the disposition of the adjoining parts, such a
collection of pus may form a tumor in the iliac fossa, which may also
fill the pelvis, or may present in the loin, closely simulating a
perinephritic abscess.
It is unfortunate when the natural walling off process has failed
and we have to deal with a spreading, generalized, septic peritonitis.
A partial compromise between these conditions sometimes appears
as a widespread yet practically localized peritonitis, in which several
loops of bowel have become affixed, and, what is worse, infected to
such an extent that they are themselves breaking down, so that
there may be impending or actual gangrene of the intestine. Such a
condition bespeaks the intensity of the infection and the
destructiveness of the infectious process, and produces a condition
which may appall the operator. The result is not only acute
obstruction of the bowel but such a local condition that one scarcely
knows where to begin or terminate his operative efforts. It was in
such a case as this that I removed eight feet and nine inches of
bowel, the last nine inches including the colon, turning in both ends
and making a lateral anastomosis, because of multiple gangrenous
patches, each of which taken alone would have required a distinct
and laborious intestinal resection, it seeming better to remove the
entire amount involved. This patient recovered and was well years
after the operation. Still other complications may disturb the
surgeon’s calculations. Thus fecal fistula may have already occurred,
or suppurative thrombophlebitis may have already produced the
beginnings or an hepatic abscess, while septic expressions within
the lungs, the heart, or elsewhere may have also occurred. In
addition to this general peritonitis, with all of its terrors, may put a
hopeless aspect upon the case.
Treatment.—Viewed in the above light it will be seen that
appendicitis is essentially a surgical disease, and that
while mild attacks may at times be successfully conducted to
resolution, or tend in that direction without treatment, the danger of
spreading infection with all its possible disasters is ever present, and
even a mild case is at no moment free from the danger of becoming
acute. Considering its widest relations, and believing in the greatest
good to the greatest number, the surgeon may easily maintain that,
save when it is too late, it is never a mistake to operate, providing
operation be properly performed. This, however, is sometimes out of
the question, and the laity occasionally assume responsibility for a
decision against the better judgment of the profession. We have to
accept, then, the fact that, no matter what the theory may be, we are
not always allowed to operate when we desire. Nevertheless if a
universal rule could be established it could be laid down in terms
such as these, that more lives would be saved by operating upon
every case of appendicitis as soon as the diagnosis has been made
or even in the presence of good reason for suspicion.
With conditions such as they are, and the fact that these cases are
usually first seen by general practitioners whose surgical judgment
has not been cultivated, and whose prejudices often actuate them, it
may be said that every case should be seen early by a surgeon, no
layman and no ordinary practitioner of small experience being in
position to assume responsibility for delay. It then remains for the
judicious and competent operator who may see such a case early,
as thus advised, to study it carefully in order to convince himself
whether there be about it good and sufficient reasons for not
operating. The most honest operator does not gainsay the possibility
of mild cases recovering without operation. He does, however,
question by which course they run greater risk.
 The following may serve as a brief summary of conditions which
justify waiting:
1. When symptoms are mild and not increasing in severity;
2. When pain and tenderness are not pronounced and
gradually subside;
3. When the pulse rate does not exceed 100;
4. When temperature is not rising nor showing abrupt
changes, especially if during the first thirty-six hours there
have been no rise. (Murphy states that if there has been no
temperature during the first thirty-six hours he begins to
doubt the diagnosis.)
5. When the belly is not distending;
6. When rigidity is not increasing and there is no evidence of
peritonitis;
7. When nausea is not increasing;
8. When neither in facial expression nor elsewhere are there
evidences of septic infection;
9. When there is no perceptible tumor in the right iliac fossa.
Under the above conditions the conservative surgeon will be
justified in waiting; being prompt, however, to intervene, should there
be change for the worse in any one of the features specified. Even
here it may be said that with conditions all as favorable as above
represented pus may be present (in small quantity) and the whole
picture may suddenly change into one of local disaster.
Finally it may be summed up in these words: When there is no
doubt as to the advisability of waiting, then wait; but in case of doubt
operate, i. e., give the patient the benefit of the doubt, which he in
this way the more certainly obtains.
Non-operative Treatment.—While thus waiting in cases which justify
it, what should be done? Absolute rest in bed, even to the extent of
using bedpan instead of commode, is the first essential. The second
comprises abstention from all food, and practically the temporary
starvation of the patient, who may be allowed water in abundance
and nothing else. Altogether too much stress has been placed upon
the so-called starvation treatment as “saving patients from
operation.” Active therapeutic treatment is limited mainly to the use
of cathartics and of anodynes, according to reason therefor. On one
hand it is not advisable to rudely stir up the large intestine, one part
of whose structure is already involved in a serious and questionable
inflammatory process; on the other hand it is not for the general
welfare of the patient to permit him to continue with a condition of
coprostasis and the ever-increasing stercoremia which it
encourages. On the whole it would seem better to clean out the
lower bowel at the earliest possible moment, after which if the patient
be properly starved there will be less necessity for subsequent active
catharsis. The question of anodynes is one of equal importance.
Those who bear pain badly, or those who suffer intensely, will
demand anodynes, which every physician knows both help to mask
the symptoms and interfere with elimination; but such cases seem to
be of themselves so violent that the extreme expression of pain
should of itself be regarded as an indication for operation. It should
be held, then, that cases which demand opiates for relief of pain
demand operation even more strongly. In the mild cases, expectantly
treated, the local application of ice may be of some value. In effect
these cases are to be treated expectantly, and, while expectant
treatment is a confession of weakness or of ignorance, it may be
unavoidable because early operation is flatly refused.
Indications for Operation.—Sufficient reasons for not operating being
absent or having passed, the following may be considered among
the more urgent indications for immediate surgical attack:
1. Continued and especially increasing pain and tenderness;
2. A rapid pulse (110 or over) tending to increase in rapidity;
3. Any rapid change in the temperature, either a sudden rise
or a drop to the normal or subnormal, without
corresponding improvement in every other particular;
4. Increasing or widespread abdominal rigidity; when the right
side of the abdomen of a sensible and non-neurotic subject
is rigid this of itself should be sufficient to justify operation;
5. The appearance of tumor in the right iliac fossa;
6. Recurring and especially constant vomiting;
7. Any indication of septic infection, local or general.
Such are the indications by which the surgeon may say upon the
instant of their recognition that a given case requires immediate
operation. Fortunate are both he and the patient if the case be seen
early, when these conditions have but lately shown themselves, and
before it be too late. It has been said that almost every death from
appendicitis means the loss of a life that might have been saved and
for which someone is responsible, this responsibility being divisible
among the patient, the parents or family, and the general practitioner
who first saw the case and was tardy in recognizing its essential
features. While patients die after late operations the surgeon himself
is rarely censurable, it not being his fault that he was called in too
late, and the patient dying of the progress of the disease in spite of
an operation and not because of it.
Operation for appendicitis may be one of the simplest and easiest
of the abdominal operations, especially when the acutely infectious
element be not present, or it may be one of the most trying and
difficult of all possible surgical procedures, taxing alike the judgment
of the experienced operator and the resources of the clinic. Much will
depend upon the time at which it is performed. If within the first forty-
eight hours the surgeon may expect to find but a small amount of
pus; if from the second to the fifth day, he may find a well-marked
collection, while later he may have not only localized abscess but
extensive complications. Again, he who operates between attacks,
during the interval or interim stage, will find conditions of adhesion
and results of old disease rather than its active products.
These operations should then be considered under these different
headings:
1. Early operations in acute cases, where there is little or no
tumor;
2. Operations in cases where abscess is present;
3. Operations in cases of more or less peritoneal involvement,
with obstruction;
4. Interval operations.
Under the above headings conditions vary so widely that they can
scarcely be spoken of or described under the same name. The seat
of the disease should first be approached. Here there is wide range
for choice of location of incision and even the method of its
performance. Some prefer the outer border of the rectus, others go
through the rectus muscle proper by an incision parallel to its fibers,
which when exposed are separated, its sheath both anteriorly and
posteriorly being divided separately. Others go through the
abdominal wall by incisions more or less oblique, and made near the
anterior superior spine, where are found the different layers of the
abdominal muscles arranged in proper order, their fibers being
disposed at right angles to each other. That incision is best in each
case which affords the shortest and easiest route to the site of the
lesion when it can be located. If tumor be present it is ordinarily best
to go in directly over it. In the absence of tumor the point of greatest
tenderness is the best guide. The possibility of subsequent hernia at
the site which is weakened by operation should be taken into
account. If it be possible to avoid drainage hernia may usually be
avoided. When drainage is necessary hernia is sometimes
unavoidable. The advantage of operation through the rectus is that
the muscle fibers can be separated without dividing them. Incision
here may, however, carry the operator so far from the site of the
appendix that he must necessarily disturb the interior arrangement
more than is advisable, and thus increase the danger of infection.
The oblique exterior incisions near the ilium always permit of
separation of the fibers of the external oblique. The deeper muscle
fibers which cross at nearly a right angle may sometimes be nicked
and widely separated by firm traction, as in the so-called “gridiron
method,” or they may require division. A short external incision is
desirable when it suffices for the purpose. Considerations of safety
(i. e., the better exposure and easier removal of the appendix) may
call in some instances for long incisions, and they should be made
sufficiently long for his purpose.
It will often happen that as the surgeon passes more deeply
toward the peritoneum he will find the tissues more or less
edematous. This is a reliable indication of the presence of pus
beneath, and should make him open the peritoneum with care and
then use extreme caution in his further manipulation, lest by
separating recent adhesions he permit pus to escape. The
peritoneum being opened sufficiently the finger is gently insinuated,
and thus the first orientation concerning internal conditions is
obtained. With the exploring finger there should be ascertained, first,
the existence of any adhesions; second, their location and relative
firmness, and, third, in a general way, the amount of surrounding
disturbance. With an appendix placed anteriorly we may thus come
directly upon it, while when placed deeply and posteriorly we may
have much to do before reaching it. After the first general exploration
the next procedure should be to protect and wall off the region
involved from the rest of the abdominal cavity by strips of gauze.
These should be long and so secured that none may be lost by
being left within the abdomen. The introduction of gauze for this
purpose will sometimes increase depression and decrease blood
pressure, but it is a necessary procedure in nearly every instance.
Moreover, several strips may be needed, and the incision may have
to be extended to a limit of two or three inches, according as further
exploration reveals a more complicated situation. The fluid pus which
may escape should be gently removed with dry gauze, or, if present
in considerable amount, be carefully conducted toward the surface.
Loops of bowel or tissue bound together by lymph should be gently
separated, as they may easily tear, or since imprisoned between
them there may be found small collections of pus. If found
gangrenous the situation is thereby seriously complicated, and it is
advisable not to restore such a loop to the abdominal cavity.
The omentum, as already indicated, may serve as a valuable
guide to the location of the appendix, which may be found wrapped
within it. It should be handled with great caution, while, at the same
time, it is made to reveal the desired information. When the
omentum is infiltrated, contorted, and adherent we may be sure of
finding pus concealed within the cavity which it helps to wall off. That
which is already gangrenous should be removed, with use of sutures
in such a way that there shall be no subsequent bleeding. It may be
found easily, or not until many other details have been mastered.
The involved appendix, when found, may be in one of the conditions
described above, all of which demand its removal save those where
this has been already accomplished by violence of the disease, in
which case the opening in the cecum may have to be closed, or one
may employ it for the purpose of an artificial anus. The appendix is
often so hard to find that any reliable guide will be welcomed. Such a
guide may be found, first, in the location and relation of the
omentum, and, secondly, in the cecum if this can be exposed, or in
either one of its firm, longitudinal, white tissue bands, which, leading
down on either side of the colon, meet and blend at the point of
origin of the appendix. Either of these followed in the right direction
leads to this spot. Conditions may be such, however, as to obscure
both of these guides, and then the colon should be followed
downward toward the ileocecal valve, or the small intestine up
toward it, in the belief that in this vicinity, and probably in the centre
of the tumor, the appendix will be found. What the surgeon shall next
do depends on the details of each case. He has not only to remove
the diseased appendix, but to ligate and separate from it its
mesentery; furthermore to separate either or both of these from
surrounding tissues or organs, e. g., the wall of the pelvis, the ovary,
the bladder, the retroperitoneal tissue above the sacrum, or from the
lateral or anterior abdominal wall. This separation may be easy, or in
its performance the tube may rupture and both pus and fecal matter
escape; or perforation may have already occurred and the operator
will be conducted into a cavity containing matter, pus and fecal
mixed, in which perhaps fecal concretions of considerable size will
be found loose. He is fortunate who, finding a condition of this kind,
finds at the same time that he is still within a circumscribed cavity.
This he should respect, and, while endeavoring to clean it thoroughly
and drain it, he will avoid doing further harm by breaking down its
walls.
Another condition which may arise after the peritoneum is opened
is that of escape of a quantity of seropurulent fluid or of almost clear
pus which is free within the abdominal cavity. There may be little or
much of this. When present it should be removed by gentle sponging
before the gauze packing is introduced. Some operators are inclined
to irrigate freely and endeavor to wash out all this contained fluid.
Others are opposed to this method and believe that gentle dry
sponging is preferable. When the appendix is found free and
movable, and when the tissues in previous contact with it are free
from evidences of destructive infection (as, for instance, when
peritoneal surfaces have not lost all their glimmer or sheen), one
should carefully remove it, cauterizing its stump, burying it beneath
the surrounding peritoneum, and close the abdomen without
drainage. In spite, however, of the assertions and actions of some
operators, I believe it to be the wisest rule to lay down for general
application that it is safer to drain in every case where free pus or
breaking down exudate is discovered.
The question of drainage thus raised is as important as any
connected with this subject. When and how shall one drain is a
question upon which hundreds of pages have been written by
various operators, and one which, while settled for individuals, can
hardly be settled for the profession at large by any brief statement.
Inefficient drainage is almost as bad as none. Efficient drainage may
call for the insertion of a tube into the depths of the pelvis, even for
counteropening in the cul-de-sac, or for additional opening in the
loin, or for the employment of two or three tubes and drains of
various kinds. A large tube loosely packed with gauze, perhaps split
through its length and abundantly provided with openings, is
probably the most effectual drain for most purposes. The cigarette
drain, of gauze wrapped in oiled silk, or a few folds of oiled silk
loosely tied together, along which fluid may percolate, may be
sufficient for cases of lesser extent. Large foul cavities are better left
more widely open, and abundantly drained with gauze packing, in
spite of the humorous stigma which has been cast upon some of
these methods by Morris with his expression “committing taxidermy
upon patients.” The depressing reflex influence of such packing
being readily conceded it may be regarded as the lesser of two evils.
Another almost equally important question is that of treatment of
the peritoneal cavity when involved. Here methods and opinions
have varied widely. A peritoneal cavity once inflamed cannot be
made absolutely clean in any way, and much reliance should be
placed on the properties of the membrane itself, which, to a large
extent, should act as its own scavenger. When, however, by
removing the parts evidently diseased we have taken away the main
source of infection we may feel like relying upon the natural
protective forces of the human body; still even here opinions differ.
Thus some would flush the abdomen with hot saline solution and
even leave some portion of it there, closing the external wound,
while others would carefully avoid the introduction of anything by
which infectious material may be spread; and while each method has
much to justify it one is scarcely found preferable to the other. I
believe, however, in thoroughly cleaning out any distinct abscess
cavity, and if the pelvis be such then I would irrigate it. I would also
thoroughly drain it.
The attention of the reader is here directed to the general
considerations found earlier in this work concerning the general
technique of abdominal operations, and the matters of drainage and
after-care, it being scarcely necessary to reiterate what has been
there said regarding the general use of saline solution locally and by
the rectum, the advantage of the Fowler position, or of Murphy’s
method of slow and gentle introduction of saline solution into the
rectum, providing for its continuous absorption, etc.
The possibility of appendicitis leading to general peritonitis, this to
acute obstruction of the bowel, and this possibly even to multiple
gangrene, has been mentioned. What should best be done under
these circumstances must depend upon the patient and upon the
surroundings. With a patient too much reduced to justify any
prolonged operation the surgeon would probably content himself with
evacuation of pus which may be readily reached, and then perhaps
by the formation of an artificial anus. Cases which will justify such
extensive operation as that above reported by myself in this
connection, where it was possible to successfully remove nearly nine
feet of intestine, will be exceedingly rare, as well as impracticable in
the ordinary private house.
A condition perhaps a little less serious but always perplexing is
that of gangrene of a limited area of cecum around a gangrenous
appendix. To remove the appendix alone in this condition is to
accomplish nothing, while to meet the indication may require the
exsection of a small area of cecal wall or the resection of the entire
cecum, or perhaps in cases of limited extent the enfolding of the
gangrenous area and the suture of its edges in such a manner that
when it sloughs it may slough into the bowel cavity.
When the surgeon sees a case of peri-appendicular (the old
perityphlitic) abscess late, and after it is easily recognized, he should
operate according to the local indication, making incision perhaps
short and placing it at a point where pus will apparently be most
easily reached and best drained. Most of these instances present
rather on the side or even in the loin behind the colon, and here a
posterior incision might be sufficient. This may here be more liberal,
since there is little danger of postoperative hernia, while through it
one may possibly expose the cecum freely and often reach even the
appendix itself. In making this opening it is well, if possible, to
separate the fibers of the transversalis by blunt dissection. Here, as
in all of the other incisions made toward the outer side of the body,
the opening should be made, if possible, obliquely and parallel to the
branches of the iliohypogastric nerves, which are thereby avoided
and loss of sensation thus prevented. In fact this posterior method is
sometimes even more rapid, and preferable in exceedingly fat
patients, while it will always cause less shock and abdominal
distress than does an anterior section; moreover, drainage takes
place in the most desirable direction.
Fecal fistula is sometimes the immediate and unavoidable,
sometimes a more or less delayed and apparently inevitable, result
or complication of some of these operations. In the former instance it
will be because of more or less gangrene or the necessity for an
immediate enterostomy. In the latter case it results from conditions
which are concealed, but may be imagined, comprising the giving
way of tissues already compromised or else being a continuation of
the ulcerative or gangrenous process. These complications are
always unpleasant and untoward, though they rarely reflect upon the
method or judgment of the operator, being essentially inevitable. If
only the fecal outflow escape externally the condition may be
regarded as inconvenient and temporary. Only in those instances in
which the peritoneal cavity is contaminated does septic peritonitis
ensue. The majority of these fecal fistulas close spontaneously by
granulation tissue. Sometimes closure is rapid, sometimes delayed,
in which latter case it may be stimulated by the use of silver nitrate,
as already indicated above. In a few instances the condition is so
extensive or so permanent as to justify or require further operation,
which may be in the nature of a curettement of the fistulous tract, a
slight plastic procedure, including a buttonhole suture about the
opening, or possibly a complete intestinal resection. I have seen
small, fistulous tracts discharge occasionally, even for years, and
then finally close spontaneously, and have far oftener seen some
form of spontaneous closure than necessity for operative
intervention. The danger of infection around any such fistulous tract
is ever present, and when it has occurred the fact will be made
known by increase of edematous granulations, with swelling and
tendency to breaking down. In every such case active cauterization,
or, better still, the use of the curette, will be required.
A tuberculous form of chronic appendicitis, as well as tuberculous
infection of a subacute exudate, is possible, the case being
converted into one of greater chronicity, with more or less mild but
constant septic features (hectic). In any event, so soon as the
tuberculous element can be recognized radical measures should be
instituted.

Fig. 583 Fig. 584

Omentum being gently lifted in order to Appendix delivered from the abdominal
uncover the appendix enclosed with its cavity and brought to view. (Lejars.)
fold. (Lejars.)
Fig. 585
 Separation of the meso-appendix. (Gosset.)

Operation for Chronic or Recurring Appendicitis; Internal Operations.—

Other things being equal the most favorable time at which to remove
the appendix is that when pathological processes are least active. If,
therefore, there be a choice the interval of quiescence rather than
the stage of active infection would be chosen. Interval operations, so
called, are usually comparatively simple, both in principle and
technique. There are times, however, when it is difficult to find a
partially obliterated appendix which has been covered up in
thickened peritoneum or partially organized exudate. In such a case
considerable blunt dissection or separation may have to be done
before it can be removed. In those instances is this particularly true
where it had originally a retroperitoneal location, and at no time a
free or movable position. When difficult of recognition we may be
unerringly led to it if we but follow the bands of white fibrous tissue
on either side of the cecum to their junction.
The opening by which the appendix should, under these
circumstances, be reached may again be made at the point of
election, and should best be located over the area of greatest
tenderness. Whatever incision is selected we should endeavor to
separate muscle bundles as much and incise as little as possible.
The appendix being delivered through the wound, either before or
after ligation of its mesentery, and being thus completely isolated, is
removed close to the large intestine, its base being tied and its
structure being seized within the blades of a forceps in such a way
that none of its contents may escape. The scissors with which it is
divided are contaminated by its contents and should not be used
again until cleansed. The stump on the proximal side may be
touched with the actual cautery, or scraped and then cauterized with
pure carbolic acid or formalin solution in order to thoroughly disinfect
it. Subsequent treatment of this stump differs with different operators.
Some are satisfied to leave it thus cauterized, while others cover it
with the adjoining peritoneum, which is brought together over the
stump end by either a purse-string or a continuous suture. Yet others
have been satisfied to invert the ends of the stump into the cecum
and thus leave it with or without further protection. It seems to make
really very little difference how the stump is treated, providing only it
be disinfected and prevented from leaking. Nevertheless it would
appear preferable to give it at least a peritoneal covering to prevent
adhesions (Figs. 583 to 588).

Fig. 586

The base of the appendix is tied with silk. The meso-appendix is being tied in
sections with the Cleveland needle. (Richardson.)
 Fig. 587 Fig. 588

Appendix surrounded with ligature at its Complete detachment of appendix.

base, after its isolation from its (Gosset.)
mesentery. Purse-string suture in place.
(Gosset.)

In the subsequent closure of the external wound drainage is not

made, there having been no pus to call for it; while the more
perfectly the wound layers be closed, each with a row of chromicized
catgut sutures, the peritoneal incision being first carefully
approximated and over it the muscle and aponeurotic layers, each
by itself, the less the tendency to subsequent postoperative hernia.
On general principles, also, the shorter the incision the less the
danger of this undesirable event. Nevertheless other considerations
should not be sacrificed to shortness and beauty of the cutaneous
scar.
The essentials of after-treatment of these cases have been
already summarized in the previous section, and to these little
exception may be taken in cases such as those above described.
Every precaution should be taken to prevent vomiting, as every
muscular effort involved in the act tends to disturb a freshly sutured
wound. While violent muscular efforts of defecation are also to be
deprecated, there is perhaps as much or more to be dreaded from
the abdominal distention which may result from inattention to free
intestinal elimination. Until the bowels have been moved it is best to
restrain the diet to the simplest fluid nourishment. So soon as
elimination becomes free more liberality in diet may be allowed.
There is the same liability to and danger from other possible
complications, such as postanesthetic pneumonia, anuria, or lack of
expulsive power of the bladder, which requires the use of the
catheter, in these as in other abdominal cases. Principles of
treatment, however, do not vary, and the reader is referred to the
previous section already indicated.
Paratyphlitic abscesses are to be distinguished from perityphlitic or
peri-appendicular abscesses in that they arise from a phlegmonous
process in the cellular tissue around the colon not due to intra-
appendicular infection. In consequence of such a cellulitis more or
less considerable collections of pus may form, which are most likely
to present either in the loin or just in front of the cecum, which may
burrow either upward or downward, or appear elsewhere. They are
mentioned here, not because they are to be differently treated or
surgically regarded, but because it is worth while to remember that
here about the cecum and ascending colon, as on the left side, such
pericolic abscesses may form without reference to the appendix.
 CHAPTER L.
THE LARGE INTESTINES AND THE RECTUM.

ANOMALIES OF THE LARGE INTESTINE.

The more common congenital anomalies of the various divisions
of the colon have to do mainly with the presence of diverticula and
atresiæ, or possibly total absence, due to defects in development.
Diverticula are much the more common. Some degree of constriction
is not particularly infrequent, but complete absence of even a section
of the colon is an extremely rare anomaly.
The acquired anomalies have to do with disease processes or
results of injury. Displacements may be the result of old adhesions
and distortions; of chronic constipation, i. e., fecal impaction and
resulting overloading, with sagging, stretching, and complete change
in shape and position; with displacement due to enlargement of other
organs, e. g., the liver, stomach, spleen, uterus, or, in milder degree,
with the gradual but inevitable and chronic results of tight lacing. The
causes which produce a gradual enteroptosis of the transverse colon
are not supposed to concern the surgeon, yet the condition may
precipitate acute obstruction which will necessitate his urgent
participation in its final treatment.
There are no diseases peculiar to the large which do not also
concern the small intestine, and no surgical diseases peculiar to it
which have not been considered in the foregoing pages. It is not,
therefore, necessary to make even a brief summary of the surgical
diseases peculiar to the large intestine. Of well-known lesions,
however, in this location there is perhaps a little worth emphasis in
this place. The most serious surgical conditions of the large bowel,
aside from the acutely obstructive, are those pertaining to
expressions of tuberculosis, syphilis, actinomycosis, dysentery in
one or other of its tropical forms, and cancer. There is a condition
also of either acute or chronic colitis or mucocolitis which may
assume such extreme degree as to necessitate a colostomy made at