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Appendicitis.

Problems:

Definition:—Appendicitis is an inflammation of the vermiform appendix, characterized by pain in the abdomen, which becomes localized over the origin of the appendix; rigidity of the right rectus muscle; a moderate febrile movement, and nausea and vomiting in the majority of cases.

Etiology:—A discussion of the etiology of this most important of acute intestinal disorders must include a recognition of the probable status of the appendix vermiformis as an organ. It is doubtless a vestigial organ in process of involution, and is therefore a locus minoris resistentiae.

Its anatomical form and relationships constitute a second reason for the frequency of appendiceal inflammation.

Its lumen is narrow and is narrowest at the neck, hence drainage is easily interfered with. By the swelling of the mucosa, micro-organisms are imprisoned within the cavity and conditions of increased warmth and moisture are established which promote bacterial growth and activity. Furthermore, the swollen condition of the tissues causes pressure upon the blood and lymph vessels, thus cutting off the resources of vital resistance. Swelling or other causes may distort the appendix, resulting in kinking or twisting of the nutrient vessels carried in the mesenteriolum, thus decreasing the vitality of the organ. The appendix has a free end, which, if the organ is long, becomes attached to nearby structures, thus causing displacement and distortion. Finally, the appendix lies in close relation to and sometimes upon the ilio-psoas muscle, and is liable to irritation when this muscle is in active use.

A predisposing factor in the occurrence of appendicitis is sex, males being more frequently attacked than females in the proportion of six to one. This is doubtless due to the more active physical life and to the more frequent causes of intestinal irritation in men than in women. In women there is also an accessory blood supply to the appendix by an artery within the appendiculo-ovarian ligament. Age seems to be an important factor in the etiology, the majority of cases occurring between the fifteenth and thirtieth years. The disease is seen in infants and in persons over sixty years of age, but not commonly. Errors in diet are important in causing many attacks, especially over-eating and the eating of indigestible food. The lumen of the appendix may be wounded by foreign bodies, as fecal concretions, which are found in twenty per cent of the cases, and by seeds or tacks and other objects, although this is rare; intestinal worms have been found in the appendix in a few cases. Traumata from the outside, as blows and falls, are sometimes followed very closely by attacks.

The micro-organisms directly responsible for the infection in cases of appendicitis are the bacillus coli communis, the pyogenic staphylococcus, the streptococcus, bacillus typhosus, and sometimes actinomyces. The most frequent of these is the bacillus coli communis, native to the bowel tract, but pathogenic only in abnormal conditions, as when the organisms are imprisoned within a swollen appendix. This bacillus is found in eighty per cent of the cases.

Symptomatology:—A consideration of the symptoms of appendicitis is closely associated with the pathological processes of the disease. Pathologically appendicitis may be divided into five distinct types. These are the catarrhal, obliterative, ulcerative, gangrenous, and perforative types.

In the catarrhal type there is hyperemia, with consequent swelling of the mucous membrane, with a free secretion of mucus. As the thickening occludes the lumen of the tube at the neck, the appendix becomes distended by the accumulating secretion. This induces pain, not only of the appendix, in its futile efforts to empty itself, but pain in the colon from reflex irritation.

After the acute process has passed, in a severe case of the catarrhal type, changes may have taken place which result in thickening of the appendix, and in slight ulceration of its mucous membranes, causing a permanent narrowing of its cavity and adhesion of its opposing surfaces in one or more places, or even throughout its entire length, thus resulting in appendicitis obliterans.

If mucus or pus be imprisoned behind the occluded area, pain, tenderness, attacks of appendicular colic and of true appendicitis occur.

In the ulcerative type the great danger is of infection of the neighboring organs by way of the uncovered blood and lymph vessels, and by perforation.

The gangrenous type of appendicitis is the type most fraught with danger to the patient, because the severest cases may show no history of previous attacks and the virulence of the infection is so great that the entire appendix sloughs away in a few hours and profound toxemia is present from the first. The strong man today, with no symptoms of appendicitis, may be a corpse tomorrow.

The perforative type arises out of any of the foregoing, though more frequently out of the obliterative, ulcerative and gangrenous types. Periappendicular abscess, pericecal abscess or general peritonitis may follow perforation.

From these considerations it is apparent that the symptoms of appendicitis vary with the type of the disease. However, there is a group of symptoms that is fairly common in occurrence and sequence and will guide in the great majority of cases to an early recognition of the disorder.

The first of these is pain, felt at first diffusely in the abdomen, but becoming localized in the appendicular region. This pain may be intense and colicky, or dull and aching in character, most frequently the former. Tenderness over the region of the appendix, "McBurney's point,"—a point two inches inward, on a line drawn from the anterior superior spine of the ilium to the umbilicus—is a fairly constant sign. Pressure at this point will elicit the maximum degree of pain, and the right rectus muscle is fixed. This is a valuable sign.

It should be remembered that the sudden cessation of pain in an attack of appendicitis is not a good sign, as it usually means the rupture of the appendix, either from distention or gangrene.

The second important symptom is a rise of temperature promptly following the onset of pain. The febrile movement is from 99° to 102° F. in adults, and may rise to 103° in children. In gangrenous appendicitis and when an abscess forms and is circumscribed, the temperature may be normal or subnormal, but the other symptoms are decidedly out of keeping with the temperature. A chill at the onset is very uncommon. Nausea and vomiting follow the onset of fever in a majority of cases. These may be called the cardinal symptoms of appendicitis.

Constipation is commonly present, though diarrhea is occasionally seen. The pulse is quick and ranges from 90 to 110. If it goes above 110 in adults, gangrene or peritonitis are to be feared.

After the first twenty-four or forty-eight hours a tumor may be palpated, usually from one and one-half to two inches above Poupart's ligament, though its position is dependent upon the position of the appendix. In many cases no tumor can be made out because of the rigidity of the rectus muscle and because of the tenderness which interferes with palpation. The urine is scanty and usually contains a trace of albumin and an excess of indican. The bladder is frequently irritable at the onset, suggesting a cystitis. Leucocytosis is frequently found, though dependence on this sign to determine operative treatment is an error. It is a sign of acute inflammation somewhere, and if other appendicular signs are present, leucocytosis is a collateral evidence.

Diagnosis:—The important syndrome is pain localizing at McBurney's point, rigidity of the right rectus muscle, fever, nausea and vomiting occurring in the order given. Early typhoid fever may simulate an attack of appendicitis because the lymph follicles of the appendiceal region are the seat of inflammation in typhoid, and the right iliac region may be painful. However, the pain in typhoid when it occurs in this region is not so great, the fever is characteristic, the spleen is swollen, there is the peculiar tympany, and the characteristic coated tongue, and always the absence of leucocytosis.

Hepatic colic is differentiated by the absence of jaundice in appendicitis; the region over the gall bladder is not tender; the pain is not referred to the back between the right scapula and the vertebral column; and by the presence of leucocytosis. Renal colic is distinguished by the reference of the pain to the pelvis, and to inner side of the thigh and testicle, the presence of blood in the urine, and there is no increase of pain on pressure over the origin of the appendix. There is no leucocytosis in renal colic. A pelvic examination will usually distinguish salpingitis and ovaritis.

Ileus is distinguished by the obstinate constipation and the development of fecal vomiting and the possible discovery of the tumor in a region separate from that of the appendix.

Prognosis:—The prognosis depends upon the severity of the infection and the consequent type of the disease. In the perforative and gangrenous types the prognosis is grave. In the catarrhal cases the outlook is good. Recurrences are frequent. Medical treatment is able to save eighty-five per cent of all cases taken together, and prompt and skilled surgical treatment in the gangrenous and perforative types can materially raise this percentage.

Treatment:—In no condition, during the past fifteen years, has there been a greater discussion, and probably a greater division of opinion than concerning the treatment of appendicitis. Space does not permit us to enter into a discussion of all of the points considered in the contention. The main argument has been for or against surgical treatment, or for or against an early operation in all cases. Suffice it to say that the consensus of opinion now is, that careful medical treatment from the start will result in a cure of perhaps ninety-five per cent of the catarrhal cases, and at least eighty-five per cent of all cases, and that in all cases which develop somewhat mildly, during the first forty-eight hours surgical operation should be delayed.

There is a class of cases in which the infection is acute and extreme, and especially in those of the gangrenous type, in which disintegration and threatened perforation are imminent from the first. In these, surgical interference will be demanded much sooner, and often the demand is immediate. The conspicuous symptoms of these cases are a rapid, feeble pulse with general prostration, great anxiety, persistent vomiting, and extreme rigidity of the rectus muscle. The pain may not be a conspicuous symptom; in fact, after the processes of gangrene are inaugurated pain may be absent.

From the experience of the best of our physicians, I am convinced that medical treatment will result in as large a percentage of cures as in any other of the severe acute inflammations, provided the conditions are thoroughly understood and the treatment is inaugurated early in the attack. It is my practice to put the patient to bed at once, after having informed him of the exact character of the disease. I then undertake to establish a fixed confidence in the curative power of medicine in his case, provided he be hopeful and willing to carry out all advised measures.

The treatment should be begun by the application of hot libradol over the diseased area. A rubber water-bag containing a little hot water should be applied over this, if the weight can be borne. By some means at least this application should be kept hot, for twenty-four or thirty-six hours. If applied over the limited area of the inflammation, it is not likely to produce nausea or other of its physiological influences. While ice or cold applications have many advocates, I am convinced that persistent heat exercises a superior physiological influence in preventing the pathological processes.

It is a good plan to carefully introduce a colonic flush and thoroughly evacuate the bowels at the beginning. At no time in the history of the case are physics—active cathartics or intestinal irritants of any kind—permissible. I am convinced that subsequent constipation, even, will do less harm than the influence of this class of remedies. However, a mild saline laxative may be needed at the first.

The use of libradol will in nearly every case so subdue the pain as to do away with the necessity of a direct pain-relieving remedy. Morphin and opium in doses sufficient to completely control pain and sensitiveness will not only mask the symptoms and prevent the diagnostician from determining the process of the disease from time to time, but they will increase blood stasis and antagonize elimination and tissue metamorphosis.

With the appearance of the fever with the circumscribed tenderness on pressure over the appendix, we have two remedies which can be depended upon. These are aconite and bryonia. If acute, intense local engorgement is suspected, belladonna should be added. A mixture should be prepared which contains twenty drops of the tincture of aconite, fifteen or twenty drops of the specific bryonia, and twenty drops of the tincture of belladonna in four ounces of water. Of this a teaspoonful should be given every hour from the start. The influence of bryonia alone will do much to relieve the pain, while its rational influence is directed toward the antagonizing of the pathological processes. In all its influences it is enforced by aconite. These agents promote tone and power in the capillary circulation, retard hypertrophy, exudation, suppuration, adhesion and induration, and hasten resolution, promoting rapid absorption of inflammatory products in a manner superior to that of any other known remedies.

In order to antagonize the formation of pus or the development of gangrene, as well as the toxic influence of the infections in this disease, twenty drops of echinacea every two or three hours should also be given from the first. With those who have used this remedy there is absolutely no question as to its efficacy. As the progress of infection leads to the necessity of surgical interference, this agent, in antagonizing the infective principles, their processes and the toxines which they form, will assist most materially in doing away with the necessity for an operation.

I have found the persistent use of pure olive oil of great advantage in this disease. It liquefies the feces without irritating the intestinal mucosa; it supplies a certain amount of nutrition; it acts as a lubricant to the mucous membranes and prevents irritation when irritants may be present. I advise from one to two ounces four or five times a day during the active stage of the disease.

While I have stated that opium must not be given to mask the symptoms, I have had cases which were severe from the start, with extreme local tenderness and acute, sharp, cutting pains, in which I have thought best to give from two to five drops of the deodorized tincture of opium every two hours for from perhaps eighteen to twenty-four hours. This reduces the sensitiveness, but does not prevent a close watch being kept upon the symptoms, nor does it increase local stasis or interfere to any extent with elimination. Occasionally the pain and soreness have so abated after five or six closes that dependence can be placed entirely upon the bryonia, and the opium should be stopped.

There is a class of these cases in which nervous symptoms develop early, with nervous irritability or excitability and increased nervous and muscular tension. These cases will be materially benefited by the use of gelsemium. It should be given in full doses, of from three to five minims of the specific medicine, every hour or two, until a condition of quietude is obtained, which will probably not require more than three or four doses. This influence conduces materially to an abatement of the total symptoms.

A number of our physicians have used lobelia, by rectal enema, where there is extreme muscular tension and nervous irritability. They claim a wide satisfactory influence from the remedy.

In recurring appendicitis it is a good plan to give from fifteen to twenty grain doses of magnesium sulphate, with five drops of dioscorea, every two or three hours. The results of this treatment are not marked at first, but are plainly apparent later on.

Where, as the case progresses and tympanites develops or mild typhoid symptoms appear, an emulsion of turpentine should be prepared, each dram of which contains three or four drops of the remedy, with one drop of the oil of wintergreen. This is given every two hours, with excellent results.

As a result of the medical treatment there should be a gradual abatement of all the symptoms after the second day. I have depended largely upon the pain and local soreness to enable me to determine the progress of the disease or the influence of the curative measures.

It must be borne in mind that even in the most favorable cases there is likely to be a tendency to recurrence of the symptoms after the treatment is suspended. Because of this fact, convalescence must be closely guarded and remedies calculated to antagonize the inflammatory processes must be continued longer than is usually thought necessary with other inflammations. This is especially true if there is any elevation of the temperature whatever. I look with suspicion upon even half of a degree of abnormal temperature.

The diet is an important factor in the treatment. It is excellent practice to exclude food of any kind for the first twenty-four hours, and, if possible, fluids also. The thirst may be quenched by a rectal injection of sterile water, or the normal salt solution, or in an urgent case, milk may be given in an enema. If the symptoms abate somewhat within twenty-four hours, liquid foods as advised in typhoid fever may be administered, but only in sufficient quantity to satisfy the urgent demand. After three or four days the diet may be gradually but very cautiously increased.

If the results of medicinal treatment are not satisfactory after the first two days, a surgeon should be consulted, and close watch should be kept for indications for operation. In recurrent cases, if the second or third attacks are at all severe, or are with difficulty controlled by the remedies indicated, it may be advisable to operate during the next interval. Statistics show that interval operations are productive of far better results than those performed during the active stage of the disease.

Inasmuch as the discomfort, local soreness and pain remain for a long time after a large proportion of the surgical operations, it may be wise when the recurring attacks are mild, and when there are no marked evidences of suppuration, to continue to treat these cases medicinally, as experience has proven that there is less discomfort from the mild recurrences than there is from the constant presence of pain and soreness after an operation. I have obtained excellent results from the persistent use of echinacea and bryonia in small doses during a period of from six to nine weeks, in cases in which there was an occasional tendency to recurrence, with an ultimate complete cure.

For a restorative and tonic treatment, in convalescence, hydrastis, bisulphate of quinin, and one-fourth of a grain of powdered ipecac, every two or three hours, will exercise a very excellent influence. The quinin and hydrastis act upon the central nervous system, while the hydrastis and ipecac act directly upon the diseased structures. Iron is often of signal service, and strychnin or strychnin arsenate, will be needed if there has been much prostration.


The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.



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