Appendage

“ Abdominal.—A number of specimens show more or less of traces of abdominal appendages on the first nine segments of the abdomen. None of these indicates the presence of a jointed appendage in any way comparable with the appendages of the cephalo-thorax, or the abdominal appendages of the trilobite. The appendages appear to be formed of clusters of branchial fringes attached to short lobes that are round or oval in outline and affixed to the ventral surface on each side of the abdomen at the outer edge of its inner third, or they may be of a lamellated structure as shown by fig. ”

“ It is a girl—clearly an appendage to the bath-tub, only her head and throat—beautiful girls have throats instead of necks—and a suggestion of shoulder appearing above the side. ”

“ The ventral side of one head shield shows faint traces of several appendages which must have presented great difficulty in their interpretation. A pair of antennules appear to spring from near the front of the lower surface, and the remainder of the organs are grouped about the mouth, which is on the median line back of the center. Handlirsch sees in these somewhat obscure appendages four pairs of biramous limbs, antennæ, mandibles, maxillulæ, and maxillæ, both branches of each consisting of short similar segments, endopodites and exopodites being alike pediform. ”

“ Natural size 5 Male genital appendage, a portion of which is scaled away furnishing a cast of the interior. × 31⁄2 6 Male genital appendage. Natural size 7 The free portion of the opercular appendage of a female showing the point of overlap and fusion of the two parts. × 2 8 Second tergite showing the antero-lateral lobes. Natural size 9 First postabdominal ring segment. Natural size 10 Half of male operculum showing the face of the median cleft. Natural size 11 Half of female operculum showing the face of the median cleft. ”

“ In considering the position of the appendages in life, one must always remember one great outstanding feature of trilobites, the thinness and flexibility of the ventral membrane. The appendages were not inserted in any rigid test but were held only by muscular and connective tissue. Hence we must premise for them great freedom of motion, and also relatively little power. The rigid appendifers, and the supporting apodemes discovered by Beecher, supplied fulcra against which they could push, but their attachment to these was rather loose. ”

“ In this last family we see a matured view of treatment, where the structural characters of anal appendages are largely used in specific differentiation, a principle not insisted on in the earlier parts of the work. ”

“ But in certain cases of appendicitis, though the surgeon knows intuitively, or, at least, suspects, that the general condition is extremely serious, the patient looks fairly well and says that he is not in pain, his pulse-rate being but little quickened and his temperature being but slightly above normal. Nevertheless, when the surgeon has opened the belly in the appendix region, he finds the appendix swollen, perforated and mortified, and lying in a stinking abscess, whilst inflammation has already spread to the neighbouring coils of intestine. ”

“ The examiner, standing at the patient's right, begins the search for the appendix by applying two, three, or four fingers of his right hand, palm surface downward, almost flat upon the abdomen, at or near the umbilicus. While now he draws the examining fingers over the abdomen in a straight line from the umbilicus to the anterior superior spine of the right ileum, he notices successively the character of the various structures as they come beneath and escape from the fingers passing over them. ”

“ In the diagnosis this is a well-defined case of appendicitis; the surgeon's knife is driven through the quivering flesh in great eagerness in search of the vermiform appendix. The bowels are rolled over and around in search of the appendix. Sometimes some substances are found in it; but often to the chargrin of the exploring physician, it is found to be in a [Pg 225] perfectly healthy and natural condition, and so seldom is it found impact with seeds or any substance whatever, that as a general rule it is a useless and dangerous experiment. ”

“ If, in a case of appendicitis, for one reason or another operation is to be delayed, what treatment should be resorted to? The patient should be put to bed with his knees resting over a pillow, and a large fomentation under oil silk should be laid over the lower part of the abdomen. No food should be given beyond an occasional sip of hot water. ”

“ My knowledge of anatomy had betrayed me.
The old doctor then gave me this homely advice, which may or may not be correct. At any rate I never forgot it. He said:—
“You’ve been eating too much and have a little indigestion and stomach-ache. But like thousands of others who have fertile imaginations, you have appendicitis—on the brain. People rarely had this disease thirty years ago. Why should they have it so frequently to-day? Is the human body so radically different from what it was a few years ago? ”

“ It does not matter whether the patient suffers from catarrhal appendicitis, with or without a foreign body in the appendix, or whether the appendix be gangrenous or perforated, he will almost invariably recover if from the beginning of the disease absolutely no food is given by mouth. ”

“ Then we have to fight nature. We have to go against the workings of nature by surgery, in order to get the person right.
In suppurative disease, such as appendicitis, it is often difficult to decide when nature is doing better than we can do, and when we can do better than nature. The appendix is a hollow tube the size of one's little finger, and hangs off from one part of the large bowel. When it gets inflamed nature at once begins the defences which I have described in the lung, namely, the walling-off process, which tends to make the bacteria harmless. ”

“ If a case has been medicated and fed to death—abused to the extent of causing a rupture into the peritoneal cavity—surgery must be resorted to as the only hope.
If a case survive an operation the patient is no wiser than he was before, and knows nothing about avoiding another attack, for let it be said loud enough to be heard by all, and with no fear of successful contradiction, that if every child at birth should have the appendix removed there would not be one case less of appendicitis than there is with the appendix intact. ”

“ A foreign body is the exciting cause in many cases, though less commonly so than was formerly imagined. The inflammation in the appendix varies in intensity from a very slight catarrhal or simple form to an ulcerative variety, and much more rarely to the acute fulminating appendicitis in which necrosis of the appendix with abscess formation occurs. ”

“ To a philosopher such questions as this must arise: Has the appendix at its entrance a sphincter muscle similar in action to that of the rectum and œsophagus? Has it the power to contract and dilate?—contract and shorten in its length and eject all substances when the nerves are in a normal condition? And where is the nerve that failed to execute the expulsion of any substance that may enter the cavity of the appendix? Has God been so forgetful as to leave the appendix in such condition as to receive foreign bodies without preparing it by contraction or otherwise to throw out such substances? ”

“ We will remove the appendix, on general principles, and that will probably be all that is needed to cure the trouble in her head.”
Under the circumstances, it was excellent advice. [259] But how much better it would have been for the unfortunate woman, whose life was thus endangered by the surgeon’s knife, if it had been recognized from the beginning that her malady was only a “hysterical simulation” of the symptoms of appendicitis. ”

“ The pull exerted by the heavy loaded cæcum upon such of the proximal portion of the appendix as is fixed by acquired adhesions to the abdo­minal wall produces a kinking of the appendix at the junction of the fixed and mobile portions. In consequence of this secretion tends to accumulate in the distal portion of the appendix and concretions form in it, or it may become more or less acutely inflamed, producing varying conditions of what is called appendicitis. ”

“ In other cases, with the same position of the appendix, the entire cæcum and greater part of the ascending colon remains free. The vertically erected appendix is closely attached to the dorsal surface of the ascending colon, included within the serous investment of the large intestine. The adhesion of the latter is confined to a limited area near the hepatic flexure. Consequently cæcum and greater part of ascending colon can be turned up, away from the parietal peritoneum of the iliac fossa, and the dorsal surface of the appendix shows the free serous covering of the adjacent large intestine. ”

“ 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. ”

“ If it were certain that the attack of appendicitis would subside and become quiescent, it would be wise to wait. But it too often happens that the first attack is, indeed, the last. Acute appendicitis is one thing; relapsing appendicitis is another. The latter condition is very manageable.
Inasmuch, then, as it is impossible to know what direction the disease will take, whether to quiescence or to disaster, it is for the greatest good in the greatest number of cases that the inflamed appendix be removed by operation whilst the disease is still limited to the appendix. ”

“ As his sensitive fingers passed over the place under which the appendix is located, he felt something that broke the smoothness of the perfect skin. It was a surgical scar. That fact alone should almost certainly rule out a present attack of appendicitis! ”

“ And until his vulnerable appendix has been removed he is never safe.
In the chronic form of the disease though the patient is never desperately ill he is never quite well. He has pains and discomfort in the abdomen, with slight tenderness and nausea, with “indigestion,” as he may call it. And as one can never tell when the smouldering inflammation may break out into conflagration, he is well advised to submit himself to operation without further delay. ”

“ In some mammals, like the rabbit, the blind gut is the bulkiest structure in the body, and bears the vermiform appendix at its far end. In man the appendix alone is left, and it tells its tale. It is interesting to notice that it is usually longer in the orang than in man, and that it is very variable, as dwindling structures tend to be. One of the unpleasant expressions of this variability is the liability to go wrong: hence appendicitis. Now these vestigial structures are, as Darwin said, like the unsounded, i.e. ”

“ Later, the skin of the lower part of the right side of the abdomen may be flushed or reddened.
This clinical picture leaves no room for doubt. The boy has an attack of acute septic inflammation of his appendix. Let it be that the symptoms have come on quickly, and that the affection is not more than ten or twelve hours old; no one can tell precisely what course the disease is going to run. It may be that with rest in bed, constant fomentations, and absolute starvation, the inflammation will subside ”

“ To carry about a diseased appendix is to run the constant risk of being laid up at a time most inconvenient, as when travelling or when staying in some place where skilled assistance is far distant or absolutely unobtainable. But having made up his mind that the appendix had better be removed, the patient can choose time, place and surgeon, and, having undergone a week’s careful training for the ordeal, can safely count on being back at work again in a month or six weeks’ time. ”

“ If an attack of acute appendicitis is allowed to take its course unoperated on, abscess forms in the peritoneal cavity in the region of the appendix, but if already inflammation has happily glued the intestines together around that area, the pus is confined within definite limits. But as the abscess increases in size the demand for its evacuation becomes urgent. The pus, under the influence of a natural law, seeks its escape by the path of least resistance; sometimes this is into the intestine, and occasionally into the bladder. ”

“ Normal condition of the scrosa above the omentum: the appendix surrounded by adhesions embedded in fecal pus? gangrenous toward its terminal portion, and showing perforation; fecal calculus in the pus; appendix movable toward the cecum."
[Just what may be expected in all cases! Nature is always busy reinforcing weak points, but the modern physician and surgeon is too wily and artful for her; she can't always anticipate his moves, hence she can't always fortify successfully.] ”

“ Appendicitis cases are found with the right knee drawn up because this relieves the tension of the abdominal muscles, and probably also of the large muscles that go to the thigh and lie behind the peritoneal cavity. In most cases of intra-abdominal pain flexing of the knees on the abdomen means much in affording relief, and patients usually discover this for themselves. There are certain apathetic patients, however, who need to be helped by suggestions. In certain of the painful conditions, due to intra-pelvic conditions, relaxation of muscles by flexion lessens the pain. ”

“ In the medical world, radical treatment of this symptom demands immediate operation and removal of the appendix. Observation of numbers of cases leads to the belief that an inflamed appendix is a symptom most rare in occurrence. The modern craze for cutting living flesh is responsible for snap judgment in diagnosis, and gas in the caecum, gall stones, inflammation of the ovary or of the bowel in the ileo-caecal region, all have been mistaken for an inflamed appendix and have occasioned unnecessary operations with serious and perhaps fatal shock. ”