=Appendicitis= is an inflammation of the appendix vermiformis. In a
few cases the cecum and surrounding tissues are involved (typhlitis,
perityphlitis). The vasomotor nerve supply comes from the lower three
dorsals and upper two lumbars. The sensory nerves make their exit from
the three lower dorsals. Appendicitis is nearly always predisposed
by injury to the innervation of the vermiform appendix and immediate
region, vertebral derangements or subdislocations from the tenth dorsal
to the third lumbar. The vermiform appendix is a peculiarly constructed
organ, and its function has not been determined with positiveness. It
undoubtedly has a function and possibly a very useful one. Sir William
Macewen[82] does not share in the general belief that the appendix is
without function, but protests against its indiscriminate removal,
believing it has a powerful influence over the function of the colon.
“Yet thousands have been operated and show no ill effect.” This is in
keeping with the ideas of Dr. Still, who always maintained that the
appendix is of importance to the human economy. Although the organ has
been found in various localities of the abdomen, this fact and others
do not necessarily indicate that it is a functionless relic. It is
richly supplied with lymphatic and blood-vessels and has a peristaltic
action peculiar to itself. When the organ is in perfect condition,
foreign material probably would not find a lodging point in it, on
account of its peristalsis. Dr. Still[83] suggests that the appendix
has a sphincter, also the power to contract, dilate or shorten, should
any foreign substance enter, and he worked with this idea in view with
uniform success. The truth of this theory has been proved by Abrams[84]
who has demonstrated by the aid of the fluoroscope that peristalsis of
the appendix can be stimulated by percussion at the 10th dorsal and it
made to empty and fill itself. Abrams makes use of this fact in the
treatment of catarrhal appendicitis. Appendicitis may also be caused
by fecal impactions and foreign bodies in the bowel contiguous to the
appendix. In these cases there is usually an impaired innervation
from the spine, due to vertebral and lower rib lesions, resulting
in a weakened muscular coat and catarrhal congestion of the mucosa.
In a word, prolapse of the bowel at this point is a predisposing
common cause. In various instances abrasions of the coats of the
tube occur, or the innervation or vascular supply is impaired, and
pathogenic bacteria, as bacilli coli communis, streptococci pyogenes,
staphylococci pyogenes aureus, typhoid bacilli, tubercle bacilli and
others, find a favorable lodging point and determine the nature of
the disease. Injuries to the spinal column and displacements of the
vertebræ in the lower dorsal and lumbar regions, straining and lifting,
tight lacing, torsion of the appendix, traumatism, impaction of feces,
concretions and foreign bodies, acute indigestion, indigestible food,
overeating, exposure to wet and cold, and infectious diseases (as
typhoid fever, tuberculosis and influenza), are all in the list of
causes of appendicitis.
=Pathologically=, in most cases the inflammation is catarrhal. This
includes many of the mild attacks. The mucosa is inflamed similarly
to catarrhal processes elsewhere, although the inflammation may
rapidly spread to the deeper structures unless immediately cared
for. The inflammation may be so severe that the lumen becomes
closed. This is termed =obliterating appendicitis=. When this occurs
the attack may cease and danger from subsequent attacks are at an
end, but inflammation may go on to purulent involvement and even
to =ulceration=, =gangrene= and =perforation= or =peritonitis=. An
=abscess= may be within or without the appendix. =Adhesions= are likely
to form about the mass.
=Symptoms.=—A sudden, violent pain in the abdomen, usually localized in
the right iliac region, although at first this pain may be general. The
point of greatest tenderness is detected over McBurney’s point—a point
at the intersection of a line between the umbilicus and the anterior
iliac spine, with a second drawn along the outer edge of the right
rectus muscle. The patient usually lies on the back with the right leg
drawn up. The severity of pain is not indicative of the seriousness. If
the pain ceases suddenly, it is commonly a serious indication. There is
usually fever at the onset, the temperature being from 100 to 102 or
even 104 degrees F., and very rarely preceded by a chill. In favorable
cases the temperature gradually falls, reaching normal in from five
to seven days. If recovery has not begun by this time an abscess
is probably forming. If =suppuration= takes place the temperature
continues with but slight fall, although in some cases there is a rise,
or it may become almost normal. Pain in the right iliac fossa, without
fever, rarely points to an acute attack of appendicitis. Vomiting and
nausea are more or less frequent, and more commonly present in the
event of perforation or rupture of an abscess. In favorable cases
vomiting rarely lasts beyond the second day. In the majority of
cases constipation is present from the beginning of the attack, due
to paralysis of the bowels. There may be diarrhea, particularly in
children.
“=Urine= is febrile in character with large quantities of indican. The
=blood= shows leucocytosis. A leucocyte count of 20,000 is high and
indicates an acute appendicitis, with pus, gangrene or peritonitis.”
On =inspection= of the abdomen at the onset of the attack, the
sides look alike, but on =palpation= there is rigidity of the
rectus abdominis muscle and the other muscles overlying the seat of
inflammation. The whole abdomen may be slightly distended. In the
majority of cases there is a progressive development of a hard swelling
or tumor in the right iliac fossa. These tumors vary in size, but
are usually oval and the size of a hen’s egg, and generally situated
a little above Poupart’s ligament. =Fluctuation= of the tumor is
indicative of suppuration. There is often great irritability of the
bladder and frequent micturition. A sudden fall in the temperature
often indicates that a perforation has taken place, or that a small
abscess has ruptured into the intestines. In favorable cases the
temperature falls at the end of the third or fourth day, the pain
lessens, the tongue becomes clearer and the bowels are moved. If the
tumor persists, the patient is very liable to have a =recurrence= of
the condition.
Rapid growth of the tumor and aggravation of the several symptoms
point to suppuration, especially =extreme tenderness= over the point
of inflammation. If the appendicitis goes on to suppuration, there
is danger of rupture into the peritoneum. In a few cases the abscess
may rupture into the bowel, in which case the patient recovers. Other
terminations are lumbar abscess, hepatic abscess and perinephritic
abscess. Death may be caused by septicemia or pylephlebitis. These
events may be delayed a variable length of time, depending upon the
extent and strength of the adhesions that form about the abscess. “The
gravity of the appendix disease lies in the fact that from the very
outset the peritoneum may be infected; the initial symptoms of pain,
with nausea and vomiting, fever, and local tenderness, present in all
cases, may indicate a widespread infection of this membrane.” (Osler).
He also says local signs are not so trustworthy as the general symptoms.
There is liability to =relapse in appendicitis=. The attacks may
recur for years at different intervals. In some cases these intervals
are very short. In some cases perfect recovery may take place after
repeated attacks.
=Diagnosis.=—In many cases the diagnosis is easy, but other cases
require careful study and close observation. Sudden pain becoming
localized, tenderness and rigidity in the right iliac region are three
symptoms that together almost positively indicate appendicitis. The
leucocyte count is of particular value. A =pseudo-appendicitis=, with
all symptoms of true appendicitis in the initial stage, may be caused
by the downward dislocation of the twelfth rib on the right side, and
occasionally the eleventh rib on the same side. The rib lies obliquely
downward toward the crest of the ilium. In a few cases the obliquity
of the lower rib is so great as to very nearly touch the ilium. The
dislocated rib may produce severe irritation, pain, tenderness,
rigidity, and even inflammation, of the abdominal muscles. The patient
nearly always complains of the pain being deeply seated, thus possibly
confusing one. In =typhoid= there is a gradual development of the
fever, characteristic temperature curve, enlargement of the spleen,
epistaxis and diarrhea. The Widal test should be made. The absence of
fever and intermittent pain in the abdomen, with complete constipation,
fecal vomiting, general distention of the abdomen, bloody stools and
marked tenesmus would determine =intestinal obstruction=. In =tubal
disease= a gradual onset, a more dull and constant pain, the history,
and pelvic examination will usually differentiate this disorder from
appendicitis. Kelly[85] gives these points in differential diagnosis,
between acute salpingitis and appendicitis: “In the former it will
usually be found that there has been a yellowish vaginal discharge
for some period before the attack. The local pain and tenderness,
usually located deeper in the pelvis, is most intense on palpation in
the region of Poupart’s ligament. On vaginal examination exquisite
tenderness is felt on either side of the uterus.” In =biliary colic=
the pain is higher along the biliary ducts and gall-bladder, extending
even as high as the shoulder, and jaundice is generally present. In
=renal colic= the pain extends along the ureters down to the inner side
of thigh and testicle, and back into lumbar region. There is absence
of fever and rigidity. The pain in =perinephritic abscess= is downward
into groin, as in nephritic colic, and there is tenderness of the
lumbar region. Exploratory incision may be necessary.
=Prognosis.=—Naturally, the prognosis depends upon the character of
the appendicitis, but on the whole the prognosis is favorable. A
large proportion of cases recover. Surgical operations are many times
deferred until too late; undoubtedly on account of the uncertainty of
the condition. Still, on the other hand, many serious cases recover
under the proper treatment when an operation seemed almost absolutely
necessary; all going to prove the fact that very much depends upon
diagnosis of the true condition. The statement that there is “no
medical treatment for appendicitis,” seems rather broad in view of the
report of the medical inspector[86] of the French Army in Algeria.
Out of 668 patients suffering from appendicitis, 188 were operated
upon and 23 died, while 408 were treated medically and only three
died. He concluded that a meat diet tended to increase the number of
cases. “It is exceedingly common and the prognosis is, on the whole
favorable. Tafft, of Copenhagen, found adhesions in the neighborhood
of the appendix in 35 percent, of all bodies subjected to post-mortem
examinations[87].
=Treatment.=—Confine the patient in bed at once. Cases have undoubtedly
been lost by not enforcing this point. Attempts should be made to
correct the disordered condition of the dorsal and lumbar regions.
Thorough and careful treatment should be given at this point, and in
most instances the pain can be relieved by correction of the disordered
vertebræ. If the case is seen at the beginning of the attack, careful
manipulation that especially lifts the cecum and surrounding structures
and local application of ice are indicated. However, great care
should be exercised here, for some of the most severe cases show no
induration. Temperature, pulse, and blood picture are invaluable as
guides. When the case is advanced, extreme care should be used in
manipulating over the swollen and inflamed region. Hot applications
will be helpful in such instances.
When due to fecal impaction and foreign bodies, thorough, direct,
elevating treatment over the involved region, and high rectal
injections are indicated. This applies to the onset, for if the disease
has progressed to the point where pus may be present, the =bowel=
must be =absolutely= at =rest=. Do not give or allow to be given
purgatives at any stage of the disease. When =sure= that =there is
no pus=, direct, careful work over the cecum and appendix is allowed
and is of value. It should be a lifting of the colon and relaxing of
nearby tissues, to promote the circulation. Treatment of the spine
is necessary in all cases, to relieve pain, to correct the nerve and
vascular supply, and to increase peristalsis so as to remove irritating
bodies from the vermiform appendix. “Colitis follows appendectomy more
frequently than any other abdominal operation. The explanation for
this is that the appendicitis is seldom localized in the appendix but
is complicated by colitis, or rather the colitis is complicated by the
appendicitis. In such cases, removal of the appendix aggravates rather
than alleviates. A conclusion to be drawn is, to carefully palpate the
colon in all appendicitis cases and reserve diagnosis, prognosis and
advising of an operation until it can be definitely determined as to
the location, extent and degree of the disease. The formation of pus is
an indication requiring immediate evacuation.
“If good surgical advantages are available and the case begins with
considerable virulence and a surgeon can be had within the first twenty
four hours, it is in all probability best to operate; but if the case
begins slowly or no good hospital advantages are available, or if the
case is not seen until some forty-eight hours have elapsed after the
onset, in all probability it is strictly an osteopathic case and should
not be touched by surgery. Some advocate in all instances to wait until
pus is formed before operative procedure is resorted to. This is a
rather dangerous attitude to take, for I have seen hundreds of cases
operated and have operated upon a great many myself and I have never
seen a case die unless it was a pus case.”—S. L. TAYLOR.[88]
The case should be most carefully watched, and a surgeon should be
promptly called for consultation if the occasion demands it in the
least; and if thought advisable, operation should be resorted to before
too late. Do not assume too much responsibility in these cases. The
patient should be nourished on a restricted diet of milk and animal
broths. Asa Willard[89] strongly recommends no food by mouth, as it
is bound to set up peristalsis and cause increased irritation. He
sustains the strength by rectal feeding. This view is held by other
authorities, even to withholding water when the inflammation is at its
height. Tasker confirms the advisability of restricted feeding and
advises resting the bowel even to the point of discontinuance of food.
The course of the attack is usually so short that there is no danger of
starvation and little loss of strength results. This point is a highly
important one in cases of any degree of severity.
In =chronic cases= of a fibrotic character, no pus, carefully lifting
the parts and loosening adhesions in addition to spinal adjustment
will often restore normal circulation. These conditions aside from the
local disorder frequently cause hyperchloridia and other digestive
disturbances.