Appendicitis by John H. Tilden (life books to read txt) 📕

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