_Etiology: _To understand the cause of appendicitis we must go back
to the beginning, and when we do we find that it starts just where
all diseases start, namely, _where health leaves off! _When the laws
of health are broken for the first time, it can be said that the
individual has started on the road of ill health. How fast he will
travel and just what will be the character of the disease he meets
with will depend upon his constitution, inheritance, environment and
education. I do not mean by education, school or book education; I
mean intuition--that knowledge which evolves from home life and
habits. I mean, has he any self-discipline? Does he know anything
about self-denial? Has he any conception of a control higher than
impulse? Has he been brought up to know that there is a limit to the
gratifying of wants and desires beyond which, if he goes, he must
make good with laws that are as exacting as they are invariable?
Does he know that nature shows no favoritism? Does he know that
there are laws regulating his intercourse with men--with
everything--that exact absolute justice from him? And that, if he
takes advantage of weakness or ignorance because he can, or if he
secures an advantage through credulity or trickery, he must settle
for the crime before a judge who is absolutely just! If he has this
education, which is a constitutional ingrafting from the mother's
blood, fructified by a like potential father, he will be almost
immune from all diseases. This is an education that can not be
secured unless the individual has the prenatal and environing
influences to differentiate these static attributes of his nature,
and, if he has, the result will be that all these qualities will
come to him because "like attracts like." In an atmosphere where
others attract evil this individual attracts good. The same is true
on the physical plane. Those who have diseased bodies always have
disease making habits, hence they attract from a given environment
all the disease making impulses, while those of healthy bodies have
health imparting habits, and attract from the same environment the
health impulses for which they have an affinity.
The constitution, inheritance and education of all mankind will vary
from the highest to the lowest types. As we go down the scale from
those with ideal physical and mental health, we see man becoming
more and more the victim of disease.
It is no uncommon thing to find people of seeming intelligence who
appear surprised when told that they have brought upon themselves
such a vulnerable state of health from wrong eating and care of
their bodies that they are in line for appendicitis, pneumonia,
typhoid fever, bowel obstruction, or blood poisoning. In such types
blood poisoning would surely follow a complicated fracture of a
bone--a fracture where the ends of the bone cut through the flesh
causing an open wound.
Pregnant women belonging to this class go into confinement with
their blood so heavily charged with the by-products of an imperfect
metabolism that they are very liable to have septicemia.
People who think they must have "three square meals a day" must
have catarrh, rheumatism, tonsilitis, quinsy, pneumonia, typhoid
fever, and all sorts of bowel trouble including appendicitis. Why!
Because three meals a day consisting of bread, potatoes, eggs, meat,
fish, butter, milk, cheese, beans, etc., overwork the metabolic
function and as a consequence organic functioning is impaired, cell
proliferation falls below the ideal, bodily resistance falls lower
and lower, the intestinal secretions lose their immunizing power
more and more, until at last the body becomes the victim of every
adverse influence. At first fermentation--indigestion--shows
occasionally; the intervals between these attacks of acid stomach,
or fermentation, grow shorter and shorter until they are of daily
occurrence; accompanying this fermentation there is gas distention
of the bowels, and this inflation in time interferes with their
motility and weakens them so that sluggishness is succeeded by
obstinate constipation.
Every step of this evolution shows an increasing toxic state of the
fluids in the bowels. After constipation is established the efforts
at securing evacuations are of such a nature as to irritate the
cecum. Drugs to force movement cause painful distentions of this
portion of the bowels. The drugs stimulate peristalsis of the small
intestine; each wave from the small intestine breaks on the walls of
the cecum, for the colon is loaded with fecal accumulations so that
the onrushing contents of the small intestine can not be received by
the colon; hence the force of the whole peristaltic impact is spent
on the cecum, which must endanger the integrity of the mucosa as
well as the musculature.
This point of the bowels, the cecum is more endangered from diarrhea
than any other. The toxic ptomaines are especially liable to create
a local infection if nothing more.
This state of the intestines--toxic state--is a constant menace to
health; in fact the organism is heavily taxed to maintain its
defense.
The overcrowding of metabolism, as explained above, the chronic
constipation and toxic bowel secretions, I recognize as the chief
factors--the necessary and leading factors--in the building and
maintaining of that constitutional state which I am pleased to
denominate _Constitutional Catarrh. _When this state is established,
it can be said that the individual is ready to develop any phase of
disease that circumstance, accident, or caprice of fortune or
environment may offer.
The constant presence of gas in the bowels becomes more and more
menacing to the cecum as the constipation increases. The filled-up
condition of the bowels--the colon and rectum--prevents the easy
passage of gas from the bowels, hence it accumulates in the
ileo-cecal region and keeps the cecum distended.
The constant dilating of the cecum from gas accumulations and the
forced dilations from diarrheas made either from drugs or irritating
foods, must not only damage the cecum but the appendix as well; for
the appendix opens into this part of the intestine and it is
reasonable to believe that it suffers distention from gas and that
toxic secretions are driven into it. When its function is not
interfered with by an unusual pressure as from constipation, no
doubt it can empty itself and does do so.
When it is understood first of all that appendicitis--the
inflammation known as appendicitis--is a local manifestation of a
general or constitutional derangement, the cause for this local
manifestation may be taken up.
In order to understand why the disease localizes we must refer the
reader to the peculiar anatomical construction of the cecum and the
appendix, and their relation to other parts. The cecum is a large,
blind pouch, one of the shortest of the several divisions in the
continuity of the intestinal canal, which begins where the small
intestine ends, and ends where the large intestine begins. Its blind
end or pouch is down; this dependent position makes it peculiarly
liable to impaction and the injuries which are disposed to come from
distention; for, as the colon ascends from its connection with the
cecum, the force of gravity must be reckoned with.
The colon is very liable to be more or less distended with
accumulations, and especially is this true of those of sedentary
habits, for a call to evacuate the bowels is frequently postponed.
This postponing of duty to nature has evolved, in all these years of
civilized life, a weakened functioning so that man is more subject
to constipation than any other animal. The bowels are educated to
tolerate a great accumulation and the pretty general habit of taking
drugs to force action has grown a weakened state which is the
natural sequence of overstimulation and as this has been going on
generation after generation it has become more or less
transmissible.
The cecum, situated as it is, must bear the brunt of the evil
effects of constipation. When the large intestine is full or
distended, as it usually is in cases of chronic constipation, so
that nothing can pass out of the cecum this organ becomes a jetty
head, so to speak, against which the peristaltic waves from the
small intestine break. The full force of the peristaltic waves from
the small intestine with its onrush of fluid or semifluid contents
subjects the cecum to great distention and strain.
If there were any way to prove that so-called appendicitis is more
common to-day than in former times, it is reasonable to believe that
the irritating effect of the pretty general habit of taking
cathartic medicine has had more to do with bringing it about than
any other one thing.
Distention, with the straining of the walls from peristaltic
onrushes as described above, and the infection that this part of the
alimentary canal is subjected to because of the decomposition of
food that is going on to a greater or less extent in all victims of
constipation, are the causes of inflammation in the cecum. If the
inflammation involves the appendix or the cecal location of the
appendix, it may be called appendicitis, but the appendix is
involved the same as any other contiguous part. Any mind capable of
reasoning should have no trouble in rightly assigning the
responsibility of this disease, if sufficient attention be given to
anatomism.
There is not any very good reason for one capable of analyzing, to
jump at the conclusion that the appendix is the cause of the disease
because it is frequently found in the field of inflammation. The
same reasoning would make Peyer's glands the cause of typhoid fever.
The unwholesome condition of the intestinal tract which is the
immediate or exciting cause of appendicitis and other diseases
peculiar to this location, is brought on by improper life; not one
cause, nor a dozen special causes, but anything and everything that
break down the general health create this condition; then add the
accidental eating of decomposition, or add decomposition,
auto-generated, and we have the necessary data.
The opening of the appendix is so very small that inflammation of
the cecum soon closes it and then we have a mucous surface without
drainage, which means obstruction--opposition to the requirements of
nature--for one of the functions of the mucous membrane is to
secrete and this secretion must have an outlet or the part becomes
diseased.
According to the theory of bacteriology a micro-organism is to blame
for appendicitis. If this were true it would relieve humanity of all
responsibility. There is a disposition on the part of man to shirk
responsibility and the germ theory is not the first theory of
vicarious atonement that he has spun. Those who wish to shirk all
kinds of responsibility by adopting the germ theory and by making
micro-organisms the scape-goat may do so, but I would advise all
sensible people to keep in mind the following truth: _Violated
hygienic laws predispose to disease; _then, when resistance is
broken down, the immediate and exciting cause may be anything
capable of laying on the "last straw."
The micro-organisms are present wherever there is life and are as
necessary to life as they are to death.
Ochsner states that in nearly all instances the disease can be
traced to the common colon bacillus, which is always present when
the intestine is normal. The three pus cocci are sometimes blamed,
and so are the bacilli of typhoid fever, tuberculosis and the ray
fungus (so-called cause of lumpjaw).
Other causes given are: Edema and congestion closing the lumen of
the appendix, thus preventing drainage; constipation; digestive
disturbances; traumatism; eating too freely while in an exhausted
condition.
"Whatever the predisposing causes may be in any given case, the
exciting cause is always some infectious material. The colon
bacillus is always present in the lumen of the alimentary canal and,
although it is harmless under normal conditions, when these
conditions arc changed and there is an abrasion, an abnormal
condition of the circulation, or a lack of drainage, it becomes at
once actively pathogenic. With a perfectly normal peritoneum a
considerable quantity of a pure culture of colon bacilli may be
injected into the abdominal cavity without causing any harmful
effect, as has been shown by the experiments of Ziegler, but if
there is any disturbance in the circulation or nutrition of the
peritoneum, the same quantity taken from the same culture will give
rise to a dangerous peritonitis."--Ochsner. [This goes back to the
constitutional derangement. First of all low resistance, then any
exciting cause is sufficient.]
In studying the cause of organic disease, the first thing to
consider is the organ itself. A knowledge of its structure and
function will indicate what diseases it is liable to have--what the
character of the disease must be.
Reason would say that an organ can be deranged in two general ways,
namely: structurally and functionally. In a structural way it may be
impaired either by coming in violent contact with extraneous
objects, or it may be crowded or pressed upon by enlarged or
displaced associate organs. In a functional way the derangement may
be brought about from overwork or underwork. A digestive organ may
be overworked by being given too much food, or food of too
stimulating a quality; or the over-stimulation may come from poisons
coming into the food from without or developing in the food after
its ingestion. The bowels may be injured by coming in violent
contact with external objects. When this is the cause there will be
the history of accident, etc.
The functions of the bowels are to furnish a dissolving fluid which
is secreted by glands situated in their structure and opening into
their lumen; besides the secreting glands they are provided with
power to excrete and absorb. The organs for the accomplishment of
these purposes, like the secretory glands, are situated in the
structure and open into the canal. Besides the functions of
secretion, excretion and absorption, the bowels act as the great
sewer of the body.
The dissolving fluids, or digestive fluids, have the power to
overcome fermentation when the general health standard is normal;
when the tone of the general health is lowered these digestive
juices are lacking in power; hence they are not able to control
fermentation if food be ingested to the amount usually taken in
health. The power to oppose fermentation by the digestive juices
ranges all the way from nil to the resistance usual to a man of full
health and vigor.
It being the function of the bowels to digest food and overcome
fermentation, it stands to reason that to accomplish this function
they must be normal--they must have a proper supply of nerve force
and the supply of nutrition must be normal or they can not furnish
the proper amount and quality of secretions. To have all these needs
supplied they must be reciprocally related to every other organ
associated with them in the organic colonization which totals a
human being.
On account of the reciprocal relationship between the bowels and the
rest of the colony of organs, the bowels must share alike; that is,
in the matter of distribution of forces no organ of the body can be
favored; all must go up and all must come down together. They must
all share alike; hence the bowels have their share of the general
tone and, if they are required to do more than a reciprocal amount
of the work, it stands to reason that they can not do good work;
and, if they can not do good work, the whole colony must suffer in a
general way, while the bowels must also suffer in a special way. The
function of drainage or sewerage is very important, and the
perversion of it brings on much ill health. The principal perversion
to the function of sewerage is that of constipation, the location of
which is limited to the lower portion of the large intestine, a
section of the canal least endowed with digestive and absorptive
power.
The result of overwork is depression--exhaustion--prostration; and
what does that mean to an organ? Is it possible for an overworked
organ--a depressed organ--an exhausted organ--a prostrated organ--to
function normally? Is it reasonable to believe that an organ that is
inflamed can function properly? Such questions are absurd, I
acknowledge. Questions that carry foregone conclusions on the face
of them write the questioner down an ass, which I also acknowledge.
But I desire to rebut the inference these questions reflect on me by
making a few requests which show that there is a lot of professional
reasoning based on that sort of logic which justifies my childish,
senseless questions.
Show me a physician, or if you can not show me one, give me the name
of a physician who does not feed children in cholera infantum. I
want to know a few physicians who do not feed in typhoid fever. I
should like to make the acquaintance of a few physicians who do not
feed in appendicitis until the disease is made desperate, and who do
not begin to feed long before it is safe to feed.
In all diseases where there is fever, in all diseases where there is
pain, _nutrition is suspended--_metabolism is stationary. I wish
some one would be kind enough to inform me of an M. D. who does not
feed patients suffering with pain and fever.
If the inferences these requests carry are true, has the personnel
of the profession any right to treat my questions with contempt and
declare that they are childish!
No! Diseased organs can not function properly and it is absurd, yes
worse than that, it is criminal to feed under such circumstances.
The result of feeding is the prolongation of disease by building it
afresh with every spoonful of food.
I say that every relapse and every complication that have ever
occurred in any disease being treated by any physician from the top
to the bottom of the profession' even if the treatment was the very
best that could be furnished by the highest skill in any of the
drug-systems, if said treatment consisted of drugging and feeding,
were brought on by the treatment.
All diseases of the alimentary canal, not of a traumatic origin or
from the accidental or intentional swallowing of corroding chemicals
or from the continuous use of drugs on the advice of physicians,
come from infection or intoxication. Why not? This is the most
reasonable cause, for the fecal matter in health is toxic and it
only requires one step further to sufficiently intensify the
putrefactive change to create irritation of the mucous membrane. Of
course there is a degree of immunization taking place all the time.
Many people have themselves inured to the constant saturation of
fecal intoxication. It is true they are building a large toleration
for that particular poison, but their general vital tone is being
lowered continually and somewhere and in some way there is a
deposition taking place. In women there may be an old cicatrix in
the neck of the womb or a lump in the breast; the circulation has
been impaired for several years and now because of the
overstimulation that has been going on so long, there is a greatly
enfeebled circulation and deposits are taking place. The tumor in
the breast becomes cancerous; the scar in the womb takes on
malignancy; the arteries harden; the circulation in the spinal cord
becomes so impaired that induration is induced followed by ataxia;
and other troubles of a like character could be mentioned. These are
the most favorable results for, while these cases are winding their
weary, sluggish course to the land of rest, there have been many
taking the rapid transit.
I wish to emphasize the fact that one of the constant symptoms
peculiar to this class of inebriates is constipation. As a class
these people carry very large quantities of fecal matter in their
lower bowels. This constantly loaded condition of the lower bowels
is relieved occasionally by a sharp, irritative diarrhea,
accompanied by nausea and vomiting or not. The diarrhea is often
preceded by a few hours of acute pain that causes some talk of
appendicitis and operation but, much to the discomfiture of the
doctor, the bowels start up and relieve all suffering.
A few of these cases develop a chronic colitis. The bowel discharges
are more or less coated with catarrhal secretion. Not all are
constipated; obstinate diarrhea is the character of some; there are
here and there a few cases that throw off a membrane two or three
times a year, often in appearance like a cast of the lumen.
Enteritis, entero-colitis and dysentery are different forms of bowel
troubles that cause much uneasiness, for it is such a common matter
to call everything appendicitis, and if the patient is credulous and
gullible he may be operated upon even if his disease is a proctitis
or a case of gas in the bowels.
It is no uncommon thing for a case of obstinate constipation,
accompanied by colic, to be operated upon for removal of the
appendix if the pain is obstinate and hangs on long enough for the
patient to be scared into an operation. The pressure from
constipation and the constant strain on the cecum render this
particular section of the bowels liable to take on local
inflammations.
The recognized literature of the day attributes all infectious
disease to germs or micro-organisms. That all diseases originating
in the alimentary canal are due to infection there can be no doubt,
and all agree, but I do not agree with the prevailing opinion that
germs or micro-organisms are the primary cause of infection, for
that theory is not sufficient; it can not possibly cover the ground
and account for everything that takes a part in the great array of
causations that must be considered. To my mind it would be just as
reasonable to say that germs cause health, and I defy any
bacteriologist to prove that micro-organisms cause disease any more
than they cause health; and if he can't prove that germs are more
pathologic than they are physiologic, but does succeed in proving
that they are equally important to health and to disease, we can
agree to that equal importance and should be able to go on agreeing
and declare that if germs are the cause of disease they must also
cause health and it is our duty to spend at least a part of our
professional time in cultivating health germs. In fact it would be
much better to spend all our time in cultivating health germs and
insisting on people being inoculated with the serum from these germs
so that there will develop such a state of health that the disease
germs will have no show.
How can a sane man forgive himself for advocating inoculation by
disease germs to cause immunization when by the use of health germs
the health could be built so strong that the pathogenic germs would
have no show. If this theory won't work both ways it is a false
theory, and professional men, who should be logical if any set of
men are logical, should be ashamed to advocate any theory that is
based upon a half-truth.
As I stated the structure and function of an organ point to its
possible maladies. The cecum is the gate-way between the large and
small intestines. Its function of passing the contents of the small
intestine into the large is obstructed much of the time. It is
constantly subjected to bruising, pressure, stretching, and
obstruction, and is, therefore, more liable to be the seat of local
inflammations than any other part of the bowels. Diseases of this
part of the bowels are liable to come at any time of the year; but
in hot weather the tendency to fermentation is much greater than at
other times of the year, and bodily resistance is reduced because of
the enervating influence of the heat, of too long working hours, and
of too short nights for sleep, and of the ever-present, omnipotent
and omnivorous appetite which is taking into the stomach and bowels
food beyond the digestive capacity both in quantity and quality; all
these join in intensifying the habitual toxcicity of the bowel
contents to such a state of virulence that those parts of the bowels
already weakened, because of the mechanical injuries before referred
to, take on a local inflammation. Diarrhea may be the consequence
and the bowels may have a thorough cleaning out and the whole
trouble end in a few days. Or the constipation may be of a nature
that evacuations, such as the patient has been having, have been
passing through the center, leaving a coating on the lumen, but
hollowed out in the center. When the inflammation starts causing
increased bowel contractions--peristalsis--there is a breaking down
of the walls of this fecal ring resulting in complete obstruction.
The ineffectual bowel contractions then serve to irritate and
inflame the affected part still more. The local inflammation is at
first superficial but the increasing toxicity of the fluids that are
held on these parts causes the inflammation to take on ulceration.
The inflammation or ulceration may remain superficial, and be
located in the lower portion of the small intestine, then the
disease is enteritis. If the bowels are cleared out and the
patient's blood freed from intoxication, the attack ends; if not the
disease will be called enteritis or catarrh. If the infection is a
little greater and extends a little deeper causes inflammation of
Peyer's glands then the type of the disease will be typhoid fever.
Children troubled with constipation will sometimes be taken with
fever and pain in the right iliac fossa and, on examination, a
fullness will be found; the sensitiveness will not be so great but
that an examination can be made and a sausage shaped tumor may be
outlined; of course, the disease will be named appendicitis and this
is enough to scare a whole neighborhood, and the child will be
carted off to a hospital and operated upon for appendicitis.
If the child is left alone, given no food, and ice put on the
sensitive parts if the temperature is 103 degree F., or hot
applications if the temperature is less, the tenderness will
probably go away in two or three days; if it does not, an abscess
will form and empty into the cecum. If the child is fed, and the
tumor manipulated--subjected to unnecessary examinations--the
abscess may be made to burrow down toward the groin, which should be
avoided for it is a very undesirable complication. The first abscess
is typhlitic, the second is perityphlitic. The first may form
without the aid of bruising in the manipulation of repeated
examinations, but the second must be forced by bad management. The
latter abscess, I have reason to believe, is the former abscess
driven, by repeated manipulations, to burrow downwards instead of
opening into the cocum.
Fecal abscess, arising from ulceration of the colon, may be mistaken
for appendicitis. There is a localized swelling, immovable in
breathing or when pressed upon, and having a tympanitic sound on
percussion over it with dull sound on pressure and heavy stroke.
The symptoms of appendicitis are: Pain in the front, lower, right
side of the abdomen. It is paroxysmal and caused in the main by
peristalsis--the regular action characteristic of the sewer function
of the bowels, which is for the purpose of forcing the contents of
the intestines onward to the outlet, and which ordinarily is carried
on without pain; but, in bowel obstructions of any kind, the onward
flow of the bowel contents is cut off resulting in great pain where
there is much irritability, for irritation of any kind always
increases this expulsive movement. Food, taken in health, stimulates
this contraction and if taken when there is inflammation--enteritis,
colitis or inflammation of any part--the contraction is increased
and necessarily painful. Think of the pain that the subject of
diarrhea has, then imagine what that pain must be if there should be
obstruction so that the fecal matter could not pass. That is as near
as I can describe what the pain of appendicitis is. Anything that
will stimulate these contractions will throw the patient into great
distress. Food or drugs will cause pain, and water, the first few
days of the illness, will do the same.
In inflammation of the cecum, where the inflammatory process remains
local and there is no obstruction more than constipation will make,
the patient will be troubled with occasional attacks of pain which
will pass as colic; or there may be a diarrhea, lasting for a day,
every few weeks or months with constipation between the attacks.
These cases may lead in time to ulceration, then to fecal abscesses
and they are often diagnosed chronic appendicitis.
When the inflammation is confined to that portion of the cecum that
gives attachment to the appendix there may be no pain, or the pain
may not be intense, and because of this lack of intensity, the
patient tolerates abuse in the line of drugging and feeding until an
abscess forms, the walls of which surround the appendix which is
inflamed and often gangrenous. About this time, on account of the
gradual increase in swelling, the pressure brings obstruction,
partial or complete, causing the symptoms to become suddenly very
dangerous; then if vigorous examinations are made to determine the
exact status of the disease, don't be surprised if rupture of the
pus sac takes place! This then demands an immediate operation which
if performed will show a gangrenous appendix that had ruptured! This
is quite common and is looked upon as proof positive that an
operation was justified; in fact, the proper and only thing to be
done, and it should have been done earlier!
This is the opinion of the majority of the profession. It really
appears that surgeons are innocent of the part they play in
rupturing unsuspected abscesses and otherwise complicating this
disease by much rough handling.
The paroxysmal pain which is characteristic of the early stages of
appendicitis may be accompanied by fever, sometimes low and
sometimes high, nausea, vomiting and diarrhea. The vomiting may be
severe and there may only be nausea. If there is much vomiting there
will usually not be much diarrhea for the excessive vomiting is an
indication that there is obstruction. In other cases there is both
nausea and diarrhea; then the obstruction is either not established,
for the trouble is as yet a local inflammation of the mucous
membrane, or the diarrhea is from the bowels below the cut-off.
It is safe to prognose obstruction when the vomiting is severe; but
if the nausea continues longer than three days, it must be due to
eating or to drugs, to taking too much water while there is nausea,
or there is more obstruction than can be accounted for by such
diseases as suppurative inflammation of the cecum or appendix.
It will be well to remember that diseases of the cecum or appendix
or both never cause complete obstruction, except in exceedingly rare
cases where adhesive bands are formed, completing the cut-off. In
this connection it will be well to also remember that in absolute
obstruction the symptoms of nausea and vomiting, or retching, will
continue, while those of appendicitis will stop in three days. In
addition to the continued nausea of complete obstruction, the pulse
grows weaker and more frequent and the patient shows great anxiety
of expression, there is a sickness that can not be accounted for
with a diagnosis of appendicitis or typhlitis, and the patient has
the appearance of being desperately sick. The great pain at the
beginning subsides, the temperature falls, the pulse grows rapid and
weak, the skin becomes leaky, the mind becomes dull, drowsy and
comatose, then a little wandering and death relieves the suffering
in a short time.
These symptoms are of collapse and they may come on in the course of
a typhoid fever, or other diseases of the alimentary canal; they
always mean a fatal toxemia either from obstruction or perforation,
and occasionally the only forerunning symptom is sudden abdominal
pain. Circumstances must guide in making a diagnosis. If, during a
run of typhoid fever, there should be sudden abdominal pain followed
with symptoms of collapse and nothing to account for it, it means
perforation; an immediate operation may save the patient; nothing
else will.
A sudden pain in the abdomen of a woman during menstrual life, with
positively no unusual menstrual symptoms and no trouble in the right
ileo-cecal region, indicates perforation of the stomach or of the
gall-bladder. If there have been a menstrual period or two gone over
with a slight showing, and some uneasiness, perhaps nausea, perhaps
a flow with pain somewhat simulating abortion, a sharp, severe
abdominal pain followed with quickening of the pulse and an
exceedingly anxious facial expression, ectopic pregnancy with
rupture of the tube may be suspected. One must also keep in mind
renal calculus in determining bowel diseases.
Authors pretty generally unite in declaring that appendicitis is a
dangerous disease. In his late book, "The Abdominal and Pelvic
Brain," Dr. Byron Robinson of Chicago says, "Appendicitis is the
most dangerous and treacherous of abdominal diseases--dangerous
because it kills and treacherous because its capricious course can
not be prognosed. . . . For years I have made it a rule to recommend
appendectomy to patients having experienced two attacks. Fifty per
cent of subjects who have had one attack experience no recurrence."
In Keating's Cyclopedia of the Diseases of Children, Dr. John B.
Deaver of Philadelphia makes the following statements:
"Appendicitis, whether acute or chronic, _is essentially a surgical
affection, _and should be placed at once under the care of a
skillful surgeon. The truth of this statement is becoming recognized
in direct proportion to the general knowledge of the course and
uncertainties of the disease, and at the present time only those who
have but a limited idea of the course of the affection and have seen
but a few cases, attempt to treat appendicitis without the advice of
a surgeon."
"Operation is the only procedure by which we can be certain of
curing our patient. It is true that some cases do recover from an
attack of appendicitis without an operation, but the percentage of
those that recover from the disease is almost nil."
"The main reason, however, why the appendix should be removed as
soon as possible is that no one can state positively what course the
disease is taking."
"Although a strong advocate of the removal of the appendix in almost
every case of inflammation of that organ, yet there are a few
conditions under which I prefer to delay operation. When we find a
patient with persistent vomiting, a leaky skin, a rapid, running
pulse, a diffuse peritonitis and signs of collapse, I believe that
operative interference is contraindicated. Under these conditions an
operation would invariably be followed by loss of life. Ice to the
abdomen, calomel pushed to free purgation, a small fly-blister below
the ensiform cartilage, nutritious enemata, with stimulants in the
form of whiskey or champagne, and hypodermics of strychnine, give a
more hopeful prospect than would operation. When the peritonitis has
subsided and the constitutional condition warrants, operation may be
performed with a much better prognosis."
The symptoms described by Dr. Deaver are those of collapse,
following perforation, diffuse peritonitis to be followed soon by
death, or of narcotism--morphine paralysis, soon to be described _in
extenso _when we come to treatment.
If the doctor ever had a patient presenting those symptoms and the
patient lived after being subjected to the treatment he recommends,
it is safe to say that he was dealing with an artificial collapse--a
drug collapse--and he did not have perforation and diffuse
peritonitis.
This statement of the eminent Philadelphia surgeon adds another very
weighty proof to my oft-repeated assertion that it matters not how
eminent the medical man may be, he cannot tell the difference
between drug and pathological symptoms. Of course this is a
humiliating statement, and it is not expected that those very
eminent medical men whom I charge with inability to differentiate
between drug collapse and the collapse due to disease, will
acknowledge that I am right, for, if their mental horizons extended
far enough for them to admit it, it would not be necessary for me to
say it.
In no other way can the atrocious mistakes that doctors make in
prognosis be accounted for. _How many, many times _doctors have
declared that a given case must end in death, and they are so
cocksure that they are right that they leave the patient to die;
some sort of a fake, mountebank or fanatic comes in, the drug
disease wears off and in a few days the patient is well. That is
exactly the sort of a case Dr. Deaver describes. The faker gets busy
with drugs that antidote the morphine poisoning, and occasionally a
patient gets well in spite of all.
In regard to surgery for this disease I shall quote from Ochsner:
"Personally, I can only second the statement made by one of the most
experienced men in this country in the surgical treatment of
appendicitis, that there are thousands of surgeons who are otherwise
competent, i. e., competent to perform the ordinary surgical and
gynecological operations, whom he would not think of permitting to
open his abdomen in case he personally suffered from an attack of
appendicitis. This condition is true not because it is an especially
difficult or dangerous operation, but because it requires an
appreciation of the conditions upon which success and failure
depend, and this appreciation can be obtained only by observing good
methods.
"In many of the ordinary surgical operations it is not necessary to
follow out the details with any great degree of accuracy, because
failure to do this will at most result in confining the patient to
bed a little longer than usual or necessary, while in the
appendicitis operation it is likely to result in the death of the
patient.
"This position, when taken in the discussion of appendicitis in
medical societies, has frequently given rise to severe criticism
because upon its face it looks as though appendicitis operations
should be performed only by the few who happen to have acquired
especial skill in this class of surgery, possibly at the expense of
the lives of a number of patients.
"This, however, is not the case. The operation is simple enough if
one will but take the pains to learn it, and every town of five
thousand inhabitants should have at least one man perfectly
competent to do such work. But if there is no such man available
then I would say most emphatically that the patient's chances of
recovery are many times greater with proper non-surgical treatment
than with an operation. Of course, patients have occasionally
recovered, by accident, in the hands of most incompetent surgeons,
but the death rate after appendicitis operations in the hands of
incompetent surgeons is absolutely frightful.
"My experience and personal observation have taught me that
physicians and surgeons, as a rule, are absolutely conscientious,
and that when they perform this operation, notwithstanding the fact
that they themselves know they are incompetent (and they alone must
necessarily be their own judges as to their competency), they do it
because they have been taught that this is the only right treatment,
and that the patient is entitled to an effort on the part of the
physician or surgeon to save the life which is in danger. I believe
that this is extremely bad teaching, and that many hundreds of lives
have been sacrificed unnecessarily on account of this. I say this
because I am confident that with proper non-operative treatment
almost all of the cases which are diagnosed reasonably early may be
carried through any acute attack, no matter what its character may
be.
"I would then say, primarily, that no case of appendicitis should be
operated upon unless a competent surgeon is available. This, of
course, does not apply to cases in which a circumscribed abscess has
formed which anyone can open with safety provided he has
sufficiently good judgment not to do anything further."
Here I must differ. If the case has not been complicated by overmuch
handling, digging, punching, thumping and otherwise manipulating in
the name of bimanual diagnosis, no one has any right to put a knife
into the pus sac for it matters not how well it is done the drainage
is bad and is in opposition to the natural outlet through the
bowels. Of course if the unfortunate patient has fallen into the
hands of some one who believes it the prerogative of a physician to
manipulate in season and out of season, and who has converted a
typhlitic abscess into a perityphlitic one, or forced the pus to
burrow towards the groin, then a free opening with a let-alone after
treatment, except thorough drainage, may be followed in time by
restoration to health; however, if the patient fully recovers it
will be more from luck than from the usual management.