Appendicitis: the Etiology, Hygenic and Dietetic Treatment

CHAPTER I.

This cut represents the back view of the cecum, the appendix, a part of the ascending colon, and the lower part of the ileum, with the arterial supply to these parts.

"A, ileo-colic artery; B and F, posterior cecal artery; C, appendicular artery; E, appendicular artery for free end; H, artery for basal end of appendix; 1, ascending or right colon; 2, external sacculus of the cecum; 3, appendix; 6, ileum; D, arteries on the dorsal surface of the ileum."--Byron Robinson.

The reader will see how very much like a blind pouch the cecum is, 2. The ileum, 6, opens into the cecum, all of the bowel below the opening being cecum, the opening of the appendix, 3, is in the lower part of the cecum.

The arterial supply to these parts is great enough to get them into trouble in those people who are imprudent eaters, and it is also great enough to save the parts when diseased if the patient has the proper treatment.

For the benefit of the lay reader I will say that the blood-vessels represented in the cut are the arteries; there are also veins, nerves, and lymphatics imbedded in the folds of the peritoneum, accompanying and paralleling the arteries, but they are not shown in the cut.

The peritoneum is the lining membrane of the peritoneal cavity. It is well to remember that there is nothing in the peritoneal cavity except a little serum. The layman will say that the bowels are in this cavity, but they are not; they project into the cavity, and their outside covering is the lining membrane of the peritoneal cavity, but they are truly on the outside of the cavity, and to enable the layman to understand the anatomy so that he can apply it when reading of the disease, I shall describe the course of an ulcer: If an ulcer starts in the bowel it first eats through the mucous coat which is the lining membrane of the bowel then through the submucous coat, which is the second layer or coat of the bowel, then through the muscular coat, which is the third layer of the bowel; this brings the ulcer to the serous coat or peritoneum. When the peritoneum is eaten through it is called perforation, for it means that there is an opening into the peritoneal cavity, and, unless the cavity is cut into, cleaned and properly drained death will take place in a very short time. I say death is inevitable without surgical treatment. In this I appear to be more radical than the most radical, for the best authors have much to say about perforation, diffuse peritonitis, and of patients who live after perforation, as though it were a common occurrence; I say they are mistaken.

CHAPTER II

History: Appendicitis did not become popularly known until about twenty years ago--not till it was christened and baptized in the blood of the surgical art. Of course the appendix has always been subject to inflammation, just as it is now, but in former years the disease we call appendicitis bore various names, depending upon the diagnostic skill of the attending physician. Typhlitis and perityphlitis were the names used to designate the disease now covered by the word appendicitis.

The diseases that appendicitis may be confounded with and must be differentiated from are obstruction, renal colic, hepatic colic, gastritis, enteritis, salpingitis, peritonitis due to gastric or intestinal ulcer, enterolith, obstipation, invagination or intussusception, hernia, external or internal, volvulus, stricture and typhoid fever.

The old text-book description of typhlitis and perityphlitis is so similar to the description of the present day appendicitis that it is not necessary to reproduce it. The symptoms given show conclusively that they are really one and the same.

In the surgical treatment of appendicitis the American profession has taken the lead, and the mention of this disease brings to mind such names as McBurney, whose name is given to an anatomical point--McBurney's Point--midway between the right anterior superior spine of the ileum and the umbilicus, Deaver of Philadelphia, and Ochsner and Murphy of Chicago. Those who are interested in the surgical treatment of the disease can look into the methods of these men, and many others. The medical literature of the day abounds in exhaustive treatises on the subject of appendicitis and its surgical treatment.

We are living in an age that will not be properly recorded unless it be entered as The Age of Fads.

Following immediately on the announcement of Lord Lister's antiseptic surgical dressing which rendered the invasion of the peritoneal cavity comparatively safe, came the laparotomy or celiotomy mania. When it was discovered that opening the abdomen was really a minor operation, it was soon legitimatized by professional opinion, and rapidly became standardized as a necessary procedure in all questionable cases--in all obscure cases of abdominal disease--where the diagnosis was in doubt. The result of popularizing and legitimatizing the exploratory incision, was to cause those who failed to resort to it, in doubtful eases, to be in contempt of the court of higher medical opinion, and to license those of a reckless, selfish, savage nature to play with human life in a manner and with a freedom that would make a barbarian envious.

The wave of abdominal operations that swept the country in the last quarter of the nineteenth century was appalling. The slightest pain during menstruation, or in the lower abdomen, in fact every pain that a woman had from head to toes was put under arrest and forced to bear false witness against the ovaries. It was a very easy matter to trump up testimony, when real evidence was embarrassing, to foregone conclusions; hence pains in obscure and foreign parts took on great importance when analyzed by minds drilled in the science of nervous reflexes, sympathies and metastases.

Normal ovariotomy (removing normal ovaries for a supposed reflex disease) swept the whole country during the eighties and threatened the unsexing of the entire female population. The ovaries had the reputation of causing all the trouble that the flesh of woman was heir to. Oophorectomy was the entering wedge, since then everything contained in the abdomen has become liable to extirpation on the slightest suspicion.

Those surgeons of greater dexterity or savagery, I can't tell which, prided themselves in operating on the more difficult cases. Taking the ovaries out was a very tame affair compared to removing the uterus, tubes and ovaries; hence the surgical adept embraced every opportunity for an excuse to remove everything that is femininely distinctive.

About 1890 appendicitis began to attract the attention of those surgically ambitious. The ovariotomy or celiotomy expert began to feel the sting of envy and jealousy aroused by those who were making history in the new surgical fad--appendectomy--and they got busy, and, as disease is not exempt from the economic law of "supply always equals demand," the disease accommodatingly sprang up everywhere; it was no time before a surgeon who had not a hundred appendectomies to his credit was not respected by the rank and file, and an aspirant for entrance to the circle of the upper four hundred could not be initiated with a record of fewer than one thousand operations.

Thanks to the law of supply and demand the ovaries retired and gave women a much needed rest. If they had continued to misbehave as they had been doing before the appendix got on the rampage, the demand for surgical work would have exceeded the supply of surgeons. Diseases of all kinds are very accommodating; as soon as a successful rival is well introduced they retire without the least show of jealousy, showing that they are not strangers to the highest ethics, their associations to the contrary notwithstanding.

There are many well written articles on appendicitis, but I believe the monograph by A. J. Ochsner, M. D., is decidedly the best, and when I refer to the best professional ideas on etiology, pathology, symptomatology and treatment I have in mind the opinions set down by Ochsner, for he has taken more advanced grounds in the medical treatment of this disease than any other physician I know anything about in this or any other country. If his "A Handbook on Appendicitis" brought out in 1902, had come out three years before, I should give him credit for being the first man on record to proscribe the taking of food in appendicitis, but as my first written advice on the subject was in the July, 1900, number of A Stuffed Club,* two years before his book, I shall give myself the credit for being the first physician to announce to the world the only correct plan of treating the disease and suggesting the probable cause which the intervening time has proven to be correct The only reason I have for making this announcement is that in all probability no one else will ever do so, and, as it is just and right that I should have the credit, I do myself the honor. The general rule is that if a new method of treatment comes out, or a discovery of importance is made other than in the regular professional channels, it will either be ignored or adopted (cribbed is more expressive) and no credit given. This is a small matter, and of no special consequence, yet it carries a meaning.

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