APPENDICITIS, OR NATURE'S REMNANT SALE
We were not made all at once, nor do we go to pieces all at once, like
the "one-hoss shay." This is largely because we are not all of the same
age, clear through. Some parts of us are older than other parts. We have
always felt a difficulty, not to say a delicacy, in determining the age
of a given member of the human species--especially of the gentler sex.
Now we know the reason of it. From the biologic point of view, we are
not an individual, but a colony; not a monarchy, but a confederacy of
organ-states, each with its millions of cell-citizens. It is not merely
editors and crowned heads who have a biologic right to say "We."
Therefore, obviously, any statement that we make as to our age can be
only in the nature of an average struck between the ages of our heart,
lungs, liver, stomach; and as these vary in ancientness by thousands of
years, the average must be both vague and misleading. The only reason
why there is a mystery about a woman's age is that she is so intensely
human and natural. The only statement as to our age that the facts would
strictly justify us in making must partake of the vagueness of Mr. A.
Ward's famous confession that he was "between twenty-three summers."
As we individually climb our own family-tree, from the first, one-celled
droplet of animal jelly up, none of our organs is older than we are,
but a number of them are younger. The appendix is one of these. Now, by
some curious coincidence, explain it as we may, some of our oldest
organs are youngest, in the sense of most vigorous, elastic, and
resisting, while some of our youngest are oldest, in the sense of
decrepit, feeble, and unstable. It is perhaps only natural that an organ
like the stomach, for instance, which has a record of honorable service
and active duty millions of years long, should be better poised, more
reliable, and more resourceful than one which, like the lung or the
appendix, has, as it were, a "character" of only about one-tenth of that
length. However this may be, the curious fact confronts us that
scattered about through the body are structures and fragments, the
remains of organs which at one time in our ancestral career were, under
the then existing circumstances, of utility and value, but have now
become mere survivals, remnants,--in the language of the day, "back
numbers." Some of these have still a certain degree of utility, though
diminished and still diminishing in size and functional importance, like
our third molars or "wisdom" teeth, our fifth or "little" toes, our
gall-bladder, our coccyx or tail-bone, the hair-glands scattered all
over the now practically hairless surface of our bodies, and our once
movable ears, which can no longer be "pricked," or laid back. These,
though of far less utility and importance than they obviously were at
one time, still earn their salt, and, though all capable of causing us
considerable annoyance on slight provocation, seldom give rise to
serious trouble or inconvenience. There are, however, a few of these
"oversights" which are of little or no known utility, and yet which,
either by their structure or situation, may become the starting-point of
serious trouble.
The best known members of this small group are the openings through the
abdominal wall, which, originally placed at the strongest and safest
position in the quadrupedal attitude, are now, in the erect attitude, at
the weakest and most dangerous, and furnish opportunity for those
serious and sometimes fatal escapes of portions of the intestines which
we call hernia; the tonsils; and our friend the _appendix vermiformis_.
For once its name expresses it exactly. It _is_ an "appendix," an
afterthought; and it is "_vermiformis_," a worm-like creature,--and,
like the worm, will sometimes turn when trodden on. Its worm-likeness is
significant in another sense also, in that it is this very
diminutiveness in size--the coils into which it is thrown, the spongy
thickness of its walls, and the readiness with which its calibre or its
circulation is blocked--that is the fundamental cause of its tendency to
disease.
The cause of appendicitis is the appendix.
"Despise not the day of small things" is good pathology as well as
Scripture. Here we have a little, worm-shaped tag, or side branch, of
the food-tube, barely three or four inches long, of about the diameter
of a small quill and of a calibre that will barely admit an ordinary
knitting needle. And yet we speak of it with bated breath. When we
remember that this little, twisted, blind tube opens directly out of one
of the largest pouches of the intestines (the _cæcum_), and that it is
easy for anything that may be present in the large pouch--food,
irritating fragments of waste matter, or bacteria--to find its way into
this fatal little trap, but very difficult to find the way out again, we
can form some idea of what a literal death-trap it may become.
How did such a useless and dangerous structure ever come to develop in a
body in which for the most part there is mutual helpfulness, utility,
and perfect smoothness of working through all the great machine? To
attempt to answer this would carry us very far back into ancient
history. But to make such backward search is absolutely the only means
of reaching an answer.
"But," some one will object, "how perfectly irrational, not to say
absurd, to propose to go back hundreds of thousands of years into
ancient history, to account for a disease which has been
discovered--according to some, invented--within the past twenty-five
years!"
Appendicitis is a mark, not a result, of a high grade of civilization.
To have had an operation for it is one of the insignia of modern rank
and culture. Our new biologic aristocracy, the "Appendix-Free," look
down with gentle disdain upon their appendiciferous fellows who still
bear in their bodies this troublesome mark of their lowly origin. In
short, the general impression prevails that appendicitis is a new
disease, a disease which has become common, or perhaps occurred at all,
only within the last quarter of a century, and which therefore--with the
usual flying leap of popular logic--is a serious menace to our future,
if it keeps on increasing in frequency and ferocity at anything like
the same rate which it has apparently shown for the past fifteen years.
As this feeling of apprehension is in many minds quite genuine, it may
be well to say briefly, before proceeding further, first, that, if there
be any disease which absolutely and almost exclusively depends upon
definite peculiarities of structure, it is appendicitis, and that these
structural peculiarities of this tiny, cramped tag of the food-canal
have existed from the earliest infancy of the race. So it is almost
unthinkable that man should not have been subject to fatal disturbances
of this organ from the very earliest times. On the post-mortem table,
the appendix of the lowest savage is the same useless, shriveled, and
inflammable worm as that of the most highly civilized Aryan, though
perhaps an inch or so longer. Secondly, there is absolutely no adequate
proof that appendicitis is increasing in frequency among civilized
races. It is only about twenty-five years ago that it was first
definitely described, and barely fifteen that the profession began at
all generally to recognize it.
But all of us whose memory extends backward a quarter of a century can
clearly recall that, while we did not see any cases of "appendicitis,"
we saw dozens of cases of "acute enteritis," "idiopathic (self-caused)
peritonitis," "acute inflammation of the bowels," "acute obstruction of
the bowels," of which patients died both painfully and promptly, and
which we now know were really appendicitis.
In short, from a careful study of all the data, including the claims so
frequently made of freedom from appendicitis on the part of Oriental
races, colored races, less civilized tribes, vegetarians, and others, we
are tending toward the conclusion that the percentage of appendicitis in
a given community is simply the percentage of its recognition,--in other
words, of the intelligence and alertness, first of its physicians, and
then of its laity. As an illustration, my friend Dr. Bloodgood kindly
had the statistics of the surgical patients treated in the great Johns
Hopkins Hospital at Baltimore investigated for me, and found almost
precisely the same percentage of cases of appendicitis among colored
patients as among white patients.
The earlier impression, first among physicians and now in the laity,
that appendicitis is an almost invariably fatal disease, is not well
founded, and we now know that a large percentage of cases recover, at
least from the first attack; so that it is quite possible for from half
to two-thirds of the cases of appendicitis actually occurring in a given
community to escape recognition, unless promptly reported, carefully
examined, and accurately diagnosed. Thirdly, in spite of the remarkable
notoriety which the disease has attained, the general dread of its
occurrence,--which has been recently well expressed in a statement that
everybody either has had it, or expects to have it, or knows somebody
who has had it,--the actual percentage of occurrence of grave
appendicitis is small. In the United States census of 1900, which was
the first census in which it was recognized as a separate cause of
death, it was responsible for only 5000 deaths in the entire United
States for the ten years preceding, or about one death in two hundred.
This rate is corroborated by the data, now reaching into thousands, from
the post-mortem rooms of our great hospitals, which report an average of
between a half and one per cent. A disease which, in spite of the
widespread terror of it, kills only one in two hundred of those who
actually die--or about one in every ten thousand of our population--is
certainly nothing to become seriously excited over from a racial point
of view.
While appendicitis is one of the "realest" and most substantial of
diseases, and, in its serious form, highly dangerous to life, there can
be little doubt that there has come, first of all, a state of mind
almost approaching panic in regard to it; and, second, a preference for
it as a diagnosis, as so much more _distingué_ than such plebeian names
as "colic," "indigestion," "enteritis," or the plain old Saxon
"belly-ache," which has reached almost the proportions of a fad. It is
certain that nowadays physicians have almost as frequently to refuse to
operate on those who are clamoring for the distinction, as to urge a
needed operation upon those unwilling to submit to it.
The satirical proposal that a "closed season" should be established by
law for appendicitis as for game birds, during which none might be
taken, would apply almost as often to the laity as to the profession,
even the surgical half.
Since the chief cause of appendicitis is the appendix, the first
question for disposal is, How did the appendix become an appendix? To
this biology can render a fairly satisfactory answer. It is the remains
of one of Mother Nature's experiments with her 'prentice hand upon the
mammalian food-tube. As is now generally known, the food-canal in
animals was originally a comparatively straight tube, running the length
of the body from mouth to anus. It early distends into a moderate pouch,
about a third of the way down from the mouth, forming a _stomach_, or
storage and churning-place for the food. Below this, it lengthens into
coils (the so-called _small intestine_), which, as the body becomes more
complex, increase in number and length until they reach four to ten
times the length of the body. Later, the lower third of the tube
distends and sacculates out into a so-called _large intestine_, in which
the last remnants of nutritive material and of moisture are extracted
from the food-residues before they are discharged from the body. Just at
the junction of this large intestine with the small intestine, nature
took it into her head to develop a second pouch, a sort of copy of the
stomach. This pouch, from the fact that it ends in a blind sac, is known
as the _cæcum_ (or "blind" pouch), and is apparently simply a means of
delaying the passage of the foodstuffs until all the nutriment and
moisture have been absorbed out of them for the service of the body.
Naturally, it has developed to the largest degree and size in those
animals which have lived upon the bulkiest and grassiest of foods, the
so-called _Herbivora_, or grass-eaters. In the _Carnivora_, or
flesh-eaters, it is usually small, and in one family, the bears,
entirely absent. This pouch is no mere figure of speech, as may be
gathered from the fact that in certain of the rodent _Herbivora_, like
the common guinea-pig, it may have a capacity equal to all of the rest
of the alimentary canal, and in the horse it will hold something like
four times as much as the stomach. Oddly enough, among the grass-eaters,
for some reason which we do not understand, it appears to occur in a
sort of inverse proportion to the stomach; those which have large,
sacculate, pouched stomachs, like the cow, sheep, and the ruminants
generally, having smaller _cæca_. In other _Herbivora_ with small
stomachs, like the rabbit and the horse, it develops greater size.
Our primitive ancestors were mixed feeders, and, though probably more
largely herbivorous than we are to-day, had a medium-sized _cæcum_, and
maintained it up to the point at which the anthropoid apes began to
branch off from our family-tree. But at about this point, for some
reason, possibly connected with the increasing variety and improved
quality and concentration of the food, due to greater intelligence and
ability to obtain it, this large _cæcum_ became unnecessary, and began
to shrivel.
Here, however, is where nature makes her first afterthought mistake.
Instead of allowing this pouch to contract and shrivel uniformly
throughout its entire length, she allowed the farther (or _distal_)
two-thirds of it to shrivel down at a much faster rate than the central
(or _proximal_) third; so that the once evenly distended sausage-shaped
pouch, about six to eight inches long and two inches in diameter, has
become distorted down into a narrow, contracted end portion, about a
quarter of an inch in diameter, and a distended first portion, for all
the world like a corncob pipe with a crooked stem and an unusually large
bowl. And behold--the modern _appendix vermiformis_, with all its fatal
possibilities!
If we want something distinctly human to be proud of, we may take the
appendix, for man is the only animal that has this in its perfection. A
somewhat similarly shriveled last four inches of the _cæcum_ is found in
the anthropoid apes and in the wombat, a burrowing marsupial of
Australia. In some of the monkeys, and in certain rodents like the
guinea-pig, a curious imitation appendix is found, which consists simply
of a contracted last four or five inches of the _cæcum_, which, however,
on distention with air, is found to relax and expand until of the same
size as the rest of the gut.
The most strikingly and distinctly human thing about us is not our
brain, but our appendix. And, while recognizing its power for mischief,
it is only fair to remember that it is an incident and a mark of
progress, of difficulties overcome, of dangers survived. In all
probability, it was our change to a more carnivorous diet, and
consequently predatory habits, which enabled our ancestors to step out
from the ruck of the "_Bandar-Log_," the Monkey Peoples. An increase in
carnivorousness must have been a powerful help to our survival, both by
widening our range of diet, so that we could live and thrive on anything
and everything we could get our hands on, and by inspiring greater
respect in the bosoms of our enemies. Let us therefore respect the
appendix as a mark and sign of historic progress and triumph, even
while recognizing to the full its unfortunate capabilities for mischief.
But what has this ancient history to do with us in the twentieth
century? Much in every way. First, because it furnishes the physical
basis of our troubles; and second, and most important, because, like
other history, it is not merely repeating itself, but continuing. This
process of shriveling on the part of the appendix is not ancient history
at all, but exceedingly modern; indeed, it is still going on in our
bodies, unless we are over sixty-five years of age.
In the first place, we have actually passed through two-thirds of this
process in our own individual experience.
At the first appearance of the _cæcum_, or blind pouch, in our prenatal
life, it is of the same calibre as the rest of the intestine, and of
uniform size from base to tip. About three weeks later the tip begins to
shrivel, and from this on the process steadily continues, until at birth
it has contracted to about one-fifteenth of the bulk of the _cæcum_. But
the process doesn't stop here, though its progress is slower. By about
the fifth year of life the stem of the cæco-appendix pipe has diminished
to about one-thirtieth of the size of the bowl, which is the proportion
that it maintains practically throughout the rest of adult life. For a
long time we concluded that the process was here finished, and that the
appendix underwent no further spontaneous changes during life; but,
after appendicitis became clearly recognized, a more careful study was
made of the condition of the appendix in bodies coming to the
post-mortem table, dead of other diseases, at all ages of life. This
quickly revealed an extraordinary and most significant fact, that, while
the appendix was no longer decreasing in apparent size, its internal
capacity or calibre was still diminishing, and at such a rate that by
the thirty-fifth year it had contracted down so as to become cut off
from the cavity of the _cæcum_ in about twenty-five to thirty per cent
of all individuals. By the forty-fifth year, according to the anatomist
Ribbert (who has made the most extensive study of the subject), nearly
fifty per cent of all appendices are found to be cut off, and by the
sixty-fifth year nearly seventy per cent.
This explains at once why appendicitis is so emphatically a disease of
young life, the largest number of cases occurring before the
twenty-fifth year (fifty per cent of all cases occur between ten and
thirty years of age), and becoming distinctly rarer after the
thirty-fifth, only about twenty per cent occurring after this age. As
soon as the cavity of the appendix is cut off from that of the
intestine, it is of course obvious that infectious or other irritating
materials can no longer enter its cavity to cause trouble, although, of
course, it is still subject to accidents due to kinks, or twists, or
interference with its blood-supply; but these are not so dangerous,
providing there be no infectious germs present.
Here, then, we have a clear and adequate physical basis for
appendicitis. A small, twisted, shriveling spur or side twig of the
intestine, opening from a point which has become a kind of settling
basin in the food-tube, its mouth gaping, as it were, to admit any
poisonous or irritating food, infectious materials, disease-germs, the
ordinary bacteria which swarm in the alimentary canal, or irritating
foreign bodies, like particles of dirt, sand, hairs, fragments of bone,
pins, etc., which may have been accidentally swallowed. Once these
irritating and infectious materials have entered it, spasm of its
muscular coat is promptly set up, their escape is blocked, and a violent
inflammation easily follows, which may end in rupture, perforation, or
gangrene.
Not only may any infection which is sweeping along the alimentary canal,
thrown off and resisted by the vigorous, full-sized, well-fed intestine,
find a point of lowered resistance and an easy victim for its attack in
the appendix, but there is now much evidence to indicate that the
ordinary bacteria which inhabit the alimentary canal, particularly that
first cousin of the typhoid bacillus, the colon bacillus, when once
trapped in this _cul-de-sac_, may quickly acquire dangerous powers and
set up an acute inflammation. It is not necessary to suppose that any
particular germ or infection causes appendicitis. Any one which passes
through, or attacks, the alimentary canal is quite capable of it, and
probably does cause its share of the attacks.
Numerous attempts have been made to show that appendicitis is
particularly likely to follow typhoid fever, rheumatism, influenza,
tonsilitis, and half a dozen other infectious or inflammatory processes.
But about all that has been demonstrated is that it may follow any of
them, though in none with sufficient frequency or constancy to enable it
to be regarded as one of the chief or even one of the important causes
of the disease.
One dread, however, we may relieve our anxious souls of, and that is the
famous grape-seed or cherry-stone terror. To use a Hibernianism, one of
our most positive conclusions in regard to the cause of appendicitis is
a negative one: that it is not chiefly, or indeed frequently, due to the
presence of foreign bodies. This was a most natural conclusion in the
early days of the disease, since, given a tiny blind pouch with a
constricted opening gaping upon the cavity of the food-canal, nothing
could be more natural than to suppose that small irritating food
remnants or foreign bodies, slipping into it and becoming lodged, would
block it and give rise to serious inflammation. And, moreover, this _a
priori_ expectation was apparently confirmed by the discovery, in many
appendices removed by operation, of small oval or rounded masses,
closely resembling the seed of some vegetable or fruit. Whereupon
anxious mothers promptly proceeded to order their children to "spit
out," with even more religious care than formerly, every grape-seed and
cherry-stone. The increased use of fresh and preserved fruits was
actually gravely cited, particularly by our Continental brethren, as one
of the causes of this new American disease. Barely ten years ago I was
spending the summer in the Adirondacks, and was bitterly reproached by
the host of one of the Lake hotels, because the profession had so
terrified the public about the dangers of appendicitis from fruit-seeds
that he was utterly unable to serve upon his tables a large stock of
delicious preserved and canned raspberries, blackberries, and grapes
which he had put up the previous years. "Why," he said, "more than half
the people that come up here will no more eat them than they would
poison, for fear that some of the seeds will give 'em appendicitis."
This dread, however, has been deprived of all rational basis, first, by
finding that many inflamed appendices removed, after the operation
became more common, contained no foreign body whatever; secondly, that
many perfectly healthy appendices examined on the post-mortem table,
death being due to other diseases, contain these apparently foreign
bodies; and thirdly, that when these "foreign bodies" were cut into,
they were found to be not seeds or pits of any description, but hardened
and, in some cases, partially calcareous masses of the fæces.
We are in a nearly similar position in regard to the third alleged cause
of appendicitis, and that is food. Many are the accusations which have
been made in this field. On the one hand, meat and animal foods
generally have been denounced, on account of their supposed "heating" or
"uric-acid-forming" properties; while on the other, vegetables and
fruits have been equally hotly incriminated, on account of their seeds,
fibres, husks, and irritating substances, and the danger of their being
contaminated by bacteria and other parasites from the soil. These
charges appear to have little adequate foundation, and, so far as we are
in a position now to judge, the only way a food can give, or be
accessory to, appendicitis is by its being taken in such excessive
amounts as to set up fermentive or putrefactive changes in the
alimentary canal, or by its being in an unsound, decaying, or actually
diseased condition. Any amounts or quality of food which are capable of
giving rise to an attack of acute indigestion may secondarily lead to an
attack of appendicitis. The only single article of diet whose ingestion
is declared by Osler to be rather frequently followed by an attack of
appendicitis is the peanut.
Therefore, the best thing to do in the way of taking precautions against
the occurrence of appendicitis is, in the language of the day, to
"forget it" as completely as possible, reassuring ourselves that, in
spite of its extraordinary notoriety and popularity, it is a
comparatively rare disease in its fatal form, responsible for not more
than one-half of one per cent of the deaths, and that the older we grow,
the better become our chances of escaping it.
Whatever we may have decided in regard to our brains, by the time we
reach fifty, we may feel reasonably sure we've no appendix.
But the question will at once arise, if the appendix be so tiny in size,
so insignificant in capacity, and so devoid of useful function, what is
the use of disturbing ourselves over the question of what may become of
it? If it is going to decay and drop off, why not permit it to do so,
with the philosophic indifference with which we would sacrifice the tip
of our little fingers in a planing-mill? Here, however, is just the rub,
and the fact that gives to appendicitis all its terrors, and to the
question of what to do in each particular case its difficulties and
perplexities.
The appendix does not, unfortunately, hang out from the surface of the
body, where it could peacefully decay and drop off without prejudice to
the rest of the body, or be quickly lopped off in the event of its
giving trouble. On the contrary, it projects its stubby and
insignificant length right into the midst of the most delicate and
susceptible cavity of the body, the general cavity of the abdomen, or
peritoneum. The thin, sensitive sheet of peritoneum which lines this
cavity covers every fold and part of the food-tube, from the stomach
down to the rectum. And when once infection or inflammation has occurred
at any point in it, there is nothing to prevent its spreading like a
prairie fire, all over the entire abdominal cavity from diaphragm to
pelvis. If this wretched little remnant were a coil of explosive fuse
within the brain-cavity itself, which any jar might set off, it could
hardly be richer in possibilities of danger.
A redeeming feature of appendicitis is that the appendix lies--so to
speak--in a corner, or wide-mouthed pouch, of the great peritoneal
cavity; and if the inflammation set up in it can be "walled off" from
the rest of the peritoneal cavity, and limited strictly to this little
corner or pouch, all will be well. This is what occurs in those cases of
severe appendicitis which spontaneously recover. If, however, this
disturbance bursts its barriers, and lights up an inflammation of the
entire peritoneal cavity, then the result is likely to be a fatal one.
Just how far nature can be trusted in each particular case to limit and
stamp out the process in this manner is the core of the problem that
confronts us, as attending physicians.
In the majority of cases, fortunately, the peritoneal fire brigade acts
promptly, pours out a wall of exudate, and locks up the appendix in a
living prison, to fight out its own battles and sink or swim by itself.
But unfortunately, in a minority of cases, by a wretched sort of
"senatorial courtesy" which exists in the body, the appendix is given
its ancestral or traditional rights and allowed to inflict its petty
troubles upon the entire abdominal cavity, and include the body in its
downfall.
Lastly come the two most pertinent and appealing questions:--
What is the outlook for me if I should develop appendicitis? And what is
to be done?
In regard to the first of these, it is safe to say that our answer is
much less alarming than it was in the earlier stage of our knowledge.
Naturally enough, in the beginning, only the severest and most
unmistakable forms of the disease and those which showed no tendency to
localization, were recognized, or at least came under the eye of the
surgeon; and as a large percentage of these resulted fatally, the
conclusion was reached, both in the medical profession and by the laity,
that appendicitis was an exceedingly dangerous disease, with a high
fatality in all cases. As, however, physicians became more expert in the
recognition of the disease, it was discovered to be vastly more common,
while side by side came the consoling knowledge that a considerable
percentage of cases got well of themselves, in the sense of the
inflammation being limited to the lower right-hand corner of the
abdominal cavity, though, of course, with the possibility of leaving a
smouldering fuse which might light up another explosion under any stress
in future.
Further, as the attention of the post-mortem investigators at our large
hospitals was directed to the subject, it was found that a very
considerable percentage of all bodies, ranging from twenty to--according
to some estimates--as high as sixty per cent, showed changes in the
appendix and its neighborhood which were believed to be due to old
inflammations; so that, while it is possible to speak only with great
caution and reserve, the balance of opinion among clinicians and
pathologists of wide experience and the more conservative surgeons
appears to be that from one-half to two-thirds of all cases of
appendicitis will recover of themselves, in the sense of subsiding more
or less permanently, without causing death.
On the other hand, it must be remembered that the appendix is an organ
which, so far as any evidence has been adduced, is entirely without
useful function; that it is in process of shriveling and disappearance,
if left entirely alone, and that the best result which can be expected
from a self-cured attack of appendicitis is the destruction of the
appendix and its elimination as a further possible cause of mischief. By
avoiding an operation in appendicitis, we may be practically certain
that we save nothing that is worth saving--except the fee. Moreover,
even though only from one-fourth to one-third of all cases develop
serious complications, you never can be quite sure in which division
your particular case will fall.
The situation is in fact a little bit like one related in the
experience of Edison, the inventor. The trustees of a church in a
neighboring town had just completed a beautiful new church building with
a high spire, projecting far above any other building in the town. When
it was nearing completion, the question arose, should they put on a
lightning-rod. The great church itself had strained their financial
resources, and one party in the board were of the opinion that they
should avoid this unnecessary expense, supporting their economic
attitude by the argument that, to put on a lightning-rod, would argue a
lack of trust in Providence. Finally, after much debate, it was decided,
as the great electrician was readily accessible, to submit the question
to him. Mr. Edison listened gravely to the arguments presented, pro and
con.
"What is the height of the building, gentlemen?"
The number of feet was given.
"How much is that above that of any surrounding structures?"
The data were supplied.
"It is a church, you say?"
"Yes."
"Well," said the great man, "on the whole, I should advise you to put on
a lightning-rod. Providence is apt to be, at times, a trifle
absent-minded."
The chances are in favor of your recovery, but--put on a lightning-rod,
in the shape of the best and most competent doctor you know, and be
guided entirely by his opinion. An attack of appendicitis is like
shooting the Grand Lachine Rapids. Probably you will come through all
right; but there is always the possibility of landing at a moment's
notice on the rocks or in the whirlpools. With a good pilot your risk
doesn't exceed a fraction of one per cent. And fortunately this
condition has been not merely theoretically but practically reached
already; for the later series of case-groups of appendicitis treated in
this intelligent way by coöperation between the physician and surgeon
from the start, with prompt interference in those cases which to the
practiced eye show signs of making trouble, has reduced the actual
recorded mortality of the disease to between two and five per cent. Even
of those cases which come to operation now, the death-rate has been
reduced as low as five per cent, in series of from 400 to 600 successive
operations. When we contrast this with the first results of operation,
when the cases as a rule were seen too late for the best time of
interference, and from twenty per cent to thirty per cent died; and with
the intermediate stage, when surgeons as a rule were inclined to advise
operation at the earliest possible moment that the disease could be
recognized, and from ten per cent to fifteen per cent died, we can see
how steady the improvement has been, and how encouraging the outlook is
for the future.
Cases which have weathered one attack of appendicitis are of course by
no means free from the risk of another. Indeed, at one time it was
believed that a recurrence was almost certain to occur. Later
investigations, based upon larger numbers of cases, now running up into
the thousands, give the reassuring result that though this danger is a
real one, it is not so great as it was at one time supposed, as the
average number in whom a second attack occurs appears to be about
twenty per cent. This, however, is a large enough risk to be worthy of
serious consideration; and in view of the fact that the mortality of
operations done between attacks is less than one per cent, it is
generally the feeling of the profession that, where there is any
appreciable soreness, or tenderness, or liability to attacks of pain in
the right iliac region, in an individual who has had one attack of
appendicitis, the really conservative and prudent procedure is to have
the source of the trouble removed once and for all.
The four principal symptoms of appendicitis are: pain, which is usually
felt most keenly somewhere between the umbilicus and the right groin,
though this is by no means invariable; tenderness in that same region
upon pressure; rigidity of the muscles of the abdominal wall on the
right side; and temperature, or fever.
No matter how much and how variegated pain you may have in the abdomen,
or how high your temperature may run, if you are not distinctly sore on
firm pressure down in this right lower or southwest quadrant of the
abdomen,--but be careful not to press too hard, it isn't safe,--you may
feel fairly sure that you haven't got appendicitis. If you are, you may
still not have it, but you'd better send for the doctor, to be sure.