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! ”

“ 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. ”

“ 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 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. ”

“ You Americans are too fond of the knife! It is not always necessary to cut out an inflamed appendix. In my hospital we have had four hundred cases of appendicitis within the last ten years, and have operated just forty times! ”

“ I continued.
“Whut, boss, dat er man come fum er monkey?”
“Yes.”
“Yes, sir, but I ain’t put no faith in it.”
“Well, I do, William; I believe that Darwin was right, and I have come to this belief since I parted with my appendix.”
“Don’t tell me, boss!”
“It is this way about your appendix,” I declared, “the man who is fartherest removed from the monkey has the smallest appendix and is most liable to have the appendicitis, and the closest, has the largest. As one becomes more civilized his appendix decreases. ”

“ 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.] ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Surgeons are often asked whether appendicitis is not a fad, and whether our grandfathers ever had appendicitis, etc. As a matter of fact, in my early professional days, appendicitis was well known. It was called “localized peritonitis” or localized “abscess,” but while the disease was very frequent, its relation to the appendix was not recognized until from his study of its pathology an American pointed it out. Even now European surgeons, with a few exceptions, are not alive to the need for operation in such cases. ”

“ Jones.
“—become insane from automobiling. He has lately developed appendicitis, and now he fancies that he is an automobile with his boiler burned out. Dr. Cutler thinks that this idea has been suggested by pain in the region of the appendix. He is a wonderful diagnostician.” ”

“ 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. ”

“ The apex of the cæcum and the entire appendix are extraperitoneal, imbedded in the loose connective tissue which occupies the area of serous obliteration. The line of peritoneal reflection from the dorsal wall of the secondary caput coli to the parietal peritoneum of the right iliac fossa is placed transversely below the true apex of the fœtal cæcum and the root of the appendix. The latter tube, imbedded in connective tissue, passes vertically upwards behind the ascending colon, its tip frequently reaching the ventral surface of the right kidney. ”

“ Jones, moodily.
“Yes—just as the steamer was about to sail——”
“But I don’t believe that I ever had real appendicitis, Agnes. I don’t much believe in all that yarn about one’s appendix, anyway. It’s got to be a sort of fad to wear your appendix trimmed close, just like your beard. I’ll make the best of mine the way it was built.”
“You are talking like a child, Worthington. Every progressive surgeon admits that it is an absolutely worthless structure——”
“That’s rank ingratitude for you! They're worth about a thousand dollars apiece to those chaps. ”

“ 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. ”

“ Acute Appendicitis. John B. Deaver says the important points that have to be learned about this disease are that it is the most common intra-abdominal inflammation; that indigestion is often a forerunner, preparing the soil for the infection; that being an infectious disease and the most common infectious disease of the abdominal cavity, the appendix constitutes the avenue by way of which infection most commonly invades the upper abdomen. ”

“ While the stomach is the organ especially liable to be injured by the swallowing of lumps of unmasticated food, the bowel may also suffer, especially the cæcum and vermiform appendix. And here we come to one of the most serious indictments against the bolting of food; though man has doubtless always suffered from appendicitis, there can be little doubt that this malady is more common now than it used to be ”

“ People died of inflammation of the bowels and peritonitis then; and as the appendix was not known as the origin of the trouble, the fateful name was not the spectre that it is now. Practically all abdominal colic—and this means 90 per centum of all the acute pain which follows gastro-intestinal disturbance in young or middle-aged adults—is due to appendicitis. It comes on, as a rule, in the midst of good health. It is very treacherous, and when the patient is apparently but slightly ill, a sudden turn for the worse may assert itself, and an intensely painful and prostrating condition develop. ”

“ Cæcum in situ lifted up to show vertical course of appendix, situated behind cæcum and ascending colon. The large intestine has a free peritoneal dorsal surface, and the appendix is held in position by adhesion to the large intestine. ”

“ Of course, technically there could be no appendicitis without an appendix, but the cecum would become inflamed just as readily.
No amount of forcing drugs given by the mouth can induce a movement from above the constriction, but a great amount of pain can be produced by attempting to force a passage. No one comprehending the true state of affairs would be foolhardy enough to try to force the bowels to move. The reader can readily imagine the great pain and danger liable to follow cathartic drugs, for they stimulate severe peristaltic contractions. ”

“ A badly ulcerated or gangrenous appendix may rupture under adjustment and be followed by diffuse peritonitis. The fragile walls of the ileum in typhoid may perforate under adjustment, while in its earlier stages the disease is easily curable. The rotted vertebral bodies in Potts’ Disease (spinal caries) may be crushed under the heavy hand of an ignorant adjuster. ”

“ In order to palpate the vermiform appendix the examiner should stand upon the right side of the woman, who is lying upon her back, and should place the tips of the fingers of the right hand at about the junction of the upper and middle thirds of a line drawn from the middle of Poupart’s ligament to the umbilicus. ”

“ The point of rupture, however, then closed, and partly perhaps to the action of fresh infectious and toxic material, perhaps only to the perforation of the appendix, may be ascribed the exacerbation of the peritonitis, that is, a renewed attack which caused the death of the patient. ”

“ The disease called appendicitis has either [pg 280] in our times become wonderfully frequent or else the improved methods of diagnosis have made us acquainted with what has long been one of the principal maladies of mankind. The appendix vermiformis seems to be a useless remnant of anatomical structure transmitted to us from a lower animal condition. At least such is the interpretation which scientists generally give to this hurtful and dangerous tube-like blind channel in connection with the bowels. ”

“ Besides the foregoing very frequent causes of appendicitis there are a few others to deal with, all of which here is out of the question; our intention is to confine ourselves to mentioning some of the more frequent causes and not to deal exhaustively with the subject, which can be found in the various hand-books on surgery. Yet we should like to mention one cause that is not infrequent, and this deals with the relation between the tonsils and the appendix. ”

“ In man it is a rudimentary structure, but in some of the lower animals it plays an important part in digestion. Inflammation of the vermiform appendix, or, more shortly, appendicitis, is not an uncommon disease, and of later years has received more attention than formerly; the dangerous illness of King Edward in 1902 especially brought this malady into prominent notice. Appendicitis is more commonly met with in children and young adults. ”

“ 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. ”