Definition.—An inflammation, acute or chronic, of the appendix vermiformis. This includes typhlitis, inflammation of the cecum, and perityphlitis, the peritoneal covering of the cecum. One can very readily see that these additional parts would be more or less involved in an acute inflammation of the appendix, and that a positive differential diagnosis can only be made postmortem.
Etiology.—In examining various authorities, we find the causes assigned as responsible for appendicitis to be legion. From congenital malformation of the appendix to peritoneal adhesions; from la grippe to tuberculosis, and of foreign bodies there seems to be no end; especially aggravating, according to some writers, are prune-seeds, cherry-stones, grape-seeds, gall-stones, pills, fish-bones, etc.; one writer stating that the most frequent cause is the pressure from pins.
Heredity has been given as predisposing to appendicitis, while the ever-present bacteria have been charged with the responsibility of producing this affection.
Blows, injuries, strains, and indigestible food, all come in for a share as the causal agent. The truth is, the cause is unknown, though in all probability, the presence of fecal matter, together with decomposed gases, are most frequently the exciting causes.
Appendicitis occurs most frequently between the ages of sixteen and thirty, and among males more often than females, the ratio being four to one.
Pathology.—The pathology depends to some extent upon the degree of the inflammation. The inflammation, beginning in the mucous membrane, may extend to the submucosa and muscular and serous coats. In the milder forms, the inflammatory process is simply catarrhal, resolution taking place without ulceration. At other times various degrees of ulceration take place; it may be confined to the mucous membrane, and do but little harm; or it may extend into the deeper tissue, or even to perforation. In interstitial appendicitis, a fibrous exudate covers the outer or serous covering, and this forms adhesions with coils of intestines, walling off the appendix from the peritoneal sac.
Where ulceration and perforation occur rapidly, this new tissue may be perforated, the pus entering the peritoneal cavity; but if slow in its formation, the adhesions become strong enough to prevent this disaster. If ulceration occurs in a part not covered by the peritoneum, and is the part next the mesocecum, a circumscribed abscess results, and there will be little danger from peritonitis. In such cases the pus will make its way out where there is the least resistance. It may be downwards along the psoas muscles, and empty into the large or small intestine, or pass upwards to the diaphragm. It has been known to empty into the bladder.
When the ulceration occurs near the cecum, the nutrient artery may be destroyed, and the appendix slough off. In such cases the opening into the bowel is usually closed by adhesions before the escape of pus into the abdomen. In some cases a fibroid change begins in the distal end of the appendix, and extends to the proximal extremity, obliterating the lumen, and giving rise to what is known as appendicitis obliterans.
Symptoms.—The disease may come on insidiously with prodromal symptoms, such as loss of appetite, slight colicky pains, and constipation, the patient complaining of some tenderness or soreness in the right side, and in walking stoops or leans toward the affected side. Generally, however, the patient is seized with a pain in the abdomen, sometimes in the region of the umbilicus; or it may be general at first, but soon locates in the right iliac fossa. At first it is paroxysmal, the patient diagnosing it as colic, though pain is elicited between paroxyms, if pressure is made over the affected spot.
At the end of twenty-four hours the pain has become constant. The position at this time is dorsal and the right leg is flexed to take off the tension by shortening the psoas and iliacus muscles. All bands of clothing are loosened, and not infrequently even the bed-clothing is not permitted to rest upon the inflamed part, the slightest pressure causing pain; a circumstance that renders a differential diagnosis from colic or indigestion quite plain.
Though the facial expression varies, the general expression is one of anxiety, which increases as the disease advances. The respiration is embarrassed, and, if the peritoneum is much involved, chiefly thoracic.
Nausea and vomiting is an early and somewhat characteristic symptom. Fever develops early, though moderate in degree, the temperature rarely going over 103° within the first forty-eight hours. In some cases no fever is present. Constipation is nearly always present, though there may be diarrhea. Frequent micturition is not an unusual symptom.
Physical examination of the abdomen reveals a slight tumor in the right iliac region, unless the peritoneum is involved and there is marked tympanites, when the abdomen is too sensitive to permit deep enough pressure to distinguish any tumefaction.
The particular point involved is McBurney's point; that is, one and a half to two inches from the anterior superior spine of the ilium, in a line drawn from it to the umbilicus. If the appendix be turned backwards, or if the tumor be small, the intervention of the distended coils of intestine may prevent its being detected by palpation. If mild, resolution will take place in a few days, by a subsidence of the fever, a yielding of the constipation, and the entire disappearance of the indurated mass in a week or ten days. In severe cases, the patient grows rapidly worse, perforation occurs, with abscess formation or diffuse peritonitis.
Diagnosis.—When a patient under forty years of age is suddenly seized with a pain in the right iliac fossa—the tender spot, McBurney's point—and there is nausea, vomiting, or obstinate constipation, and the patient lies on the back with the right leg drawn up, and an indurated tumor develops at the seat of pain, there is but little doubt as to the nature of the case.
Prognosis.—Although a grave disease, I am satisfied that a large per cent will recover if not subjected to the use of the knife. Where perforation with abscess formation occurs, the only recourse, and the one that promises the only relief, is operation; but these will be found few in number if the patient be seen early.
Treatment.—While I am opposed to the use of active cathartics, I am satisfied that the administration of small doses of salts is very beneficial, or olive-oil may be substituted for the saline. At the same time enemas of warm water and glycerin will assist materially in opening the bowels. It may be necessary to use a rectal tube, introducing it as rapidly as the bowel fills with water. In this way the tube may be carried up to the transverse colon, and even beyond this in many cases. Too great force, however, must not be used in this method. Lobelia used in the enema will give splendid results.
Where there is fever, aconite or veratrum may be used with much benefit; and where there is severe colicky pain, colocynth will often give relief. Where the pain becomes unbearable, or the patient is constantly calling for relief, a hypodermic of morphia should be used, though opiates, as a rule, should not be given. Where abscess formation takes place, and there is no evidence of its pointing to the abdominal walls or of perforating the intestine, the surgeon should be called.
In recurring appendicitis—that is, after a patient has had three or more attacks of the disease, and is well during the interval between attacks—it is better to have the offending organ removed.