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Created by Steve Solomon

Created by Steve Solomon

APPENDICITIS

THE ETIOLOGY, HYGIENIC AND DIETETIC TREATMENT

BY JOHN H. TILDEN, M.D.

Author of

"Impaired Health," 2 Vol.; "Cholera Infantum," "Typhoid Fever," "Diseases of Women and Easy Childbirth," "Venereal Diseases," "Appendicitis," "Care of Children," "Food," 2 Vol.; "Pocket Dietitian."

You have recently purchased some of my earlier writings, hence the following suggestion:

In some of my former writings this correction has not yet been made, therefore we are asking our readers to keep this in mind when studying those particular works. Where you find milk in combination with starch, change the milk to teakettle tea, which means hot water with a little cream and a small amount of sugar.

In some of my former writings this correction has not yet been made, therefore we are asking our readers to keep this in mind when studying those particular works. Where you find milk in combination with starch, change the milk to teakettle tea, which means hot water with a little cream and a small amount of sugar.

THE ROAD OF ILL HEALTH

APPENDICITIS

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.

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.

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 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.

Previous to 1890 the most popular treatment was probably the giving of opium; although this was far from ideal, "it had the advantage of taking away the patient's appetite, relieving pain, and putting the bowels to rest."--Ochsner. If there were any way to prove it, we should find that next to surgery opium is still the most popular way of treating the disease.

To-day there is no other disease which brings surgery so quickly to mind as does appendicitis, especially if the victim can stand for a good, large fee. It is only human I presume, for surgeons to defend the operation. They believe in it, and are not willing to investigate, for they are satisfied. They know or should know that ninety per cent of all the surgery practiced to-day has no excuse for its existence--no more right to be protected by the laws that weld society together than has any other graft that exists by the grace of public ignorance and credulity. This operation has for some time been the largest single item of revenue for the profession.

Thirty-four years ago I was called in consultation to see my first case of what was then generally recognized as perityphlitis or typhlitis--inflammation of the connective tissue about the cecum. It was a typical case of what is today called appendicitis. I advised the doctor to cease his fruitless endeavors at securing relief by giving drugs, and give the patient nothing but water. As I remember now, it took about four weeks for this patient to recover. This plan--positively nothing but water--has since been a part of my treatment in all such diseases.

The constitution, inheritance and education of all mankind will vary from the highest to the lowest types. As we go down the scale from those with ideal physical and mental health, we see man becoming more and more the victim of disease.

It is no uncommon thing to find people of seeming intelligence who appear surprised when told that they have brought upon themselves such a vulnerable state of health from wrong eating and care of their bodies that they are in line for appendicitis, pneumonia, typhoid fever, bowel obstruction, or blood poisoning. In such types blood poisoning would surely follow a complicated fracture of a bone--a fracture where the ends of the bone cut through the flesh causing an open wound.

Pregnant women belonging to this class go into confinement with their blood so heavily charged with the by-products of an imperfect metabolism that they are very liable to have septicemia.

People who think they must have "three square meals a day" must have catarrh, rheumatism, tonsilitis, quinsy, pneumonia, typhoid fever, and all sorts of bowel trouble including appendicitis. Why! Because three meals a day consisting of bread, potatoes, eggs, meat, fish, butter, milk, cheese, beans, etc., overwork the metabolic function and as a consequence organic functioning is impaired, cell proliferation falls below the ideal, bodily resistance falls lower and lower, the intestinal secretions lose their immunizing power more and more, until at last the body becomes the victim of every adverse influence. At first fermentation--indigestion--shows occasionally; the intervals between these attacks of acid stomach, or fermentation, grow shorter and shorter until they are of daily occurrence; accompanying this fermentation there is gas distention of the bowels, and this inflation in time interferes with their motility and weakens them so that sluggishness is succeeded by obstinate constipation.

Every step of this evolution shows an increasing toxic state of the fluids in the bowels. After constipation is established the efforts at securing evacuations are of such a nature as to irritate the cecum. Drugs to force movement cause painful distentions of this portion of the bowels. The drugs stimulate peristalsis of the small intestine; each wave from the small intestine breaks on the walls of the cecum, for the colon is loaded with fecal accumulations so that the onrushing contents of the small intestine can not be received by the colon; hence the force of the whole peristaltic impact is spent on the cecum, which must endanger the integrity of the mucosa as well as the musculature.

This point of the bowels, the cecum is more endangered from diarrhea than any other. The toxic ptomaines are especially liable to create a local infection if nothing more.

This state of the intestines--toxic state--is a constant menace to health; in fact the organism is heavily taxed to maintain its defense.

The constant presence of gas in the bowels becomes more and more menacing to the cecum as the constipation increases. The filled-up condition of the bowels--the colon and rectum--prevents the easy passage of gas from the bowels, hence it accumulates in the ileo-cecal region and keeps the cecum distended.

The constant dilating of the cecum from gas accumulations and the forced dilations from diarrheas made either from drugs or irritating foods, must not only damage the cecum but the appendix as well; for the appendix opens into this part of the intestine and it is reasonable to believe that it suffers distention from gas and that toxic secretions are driven into it. When its function is not interfered with by an unusual pressure as from constipation, no doubt it can empty itself and does do so.

When it is understood first of all that appendicitis--the inflammation known as appendicitis--is a local manifestation of a general or constitutional derangement, the cause for this local manifestation may be taken up.

In order to understand why the disease localizes we must refer the reader to the peculiar anatomical construction of the cecum and the appendix, and their relation to other parts. The cecum is a large, blind pouch, one of the shortest of the several divisions in the continuity of the intestinal canal, which begins where the small intestine ends, and ends where the large intestine begins. Its blind end or pouch is down; this dependent position makes it peculiarly liable to impaction and the injuries which are disposed to come from distention; for, as the colon ascends from its connection with the cecum, the force of gravity must be reckoned with.

The colon is very liable to be more or less distended with accumulations, and especially is this true of those of sedentary habits, for a call to evacuate the bowels is frequently postponed.

This postponing of duty to nature has evolved, in all these years of civilized life, a weakened functioning so that man is more subject to constipation than any other animal. The bowels are educated to tolerate a great accumulation and the pretty general habit of taking drugs to force action has grown a weakened state which is the natural sequence of overstimulation and as this has been going on generation after generation it has become more or less transmissible.

The cecum, situated as it is, must bear the brunt of the evil effects of constipation. When the large intestine is full or distended, as it usually is in cases of chronic constipation, so that nothing can pass out of the cecum this organ becomes a jetty head, so to speak, against which the peristaltic waves from the small intestine break. The full force of the peristaltic waves from the small intestine with its onrush of fluid or semifluid contents subjects the cecum to great distention and strain.

If there were any way to prove that so-called appendicitis is more common to-day than in former times, it is reasonable to believe that the irritating effect of the pretty general habit of taking cathartic medicine has had more to do with bringing it about than any other one thing.

Distention, with the straining of the walls from peristaltic onrushes as described above, and the infection that this part of the alimentary canal is subjected to because of the decomposition of food that is going on to a greater or less extent in all victims of constipation, are the causes of inflammation in the cecum. If the inflammation involves the appendix or the cecal location of the appendix, it may be called appendicitis, but the appendix is involved the same as any other contiguous part. Any mind capable of reasoning should have no trouble in rightly assigning the responsibility of this disease, if sufficient attention be given to anatomism.

There is not any very good reason for one capable of analyzing, to jump at the conclusion that the appendix is the cause of the disease because it is frequently found in the field of inflammation. The same reasoning would make Peyer's glands the cause of typhoid fever.

The unwholesome condition of the intestinal tract which is the immediate or exciting cause of appendicitis and other diseases peculiar to this location, is brought on by improper life; not one cause, nor a dozen special causes, but anything and everything that break down the general health create this condition; then add the accidental eating of decomposition, or add decomposition, auto-generated, and we have the necessary data.

The opening of the appendix is so very small that inflammation of the cecum soon closes it and then we have a mucous surface without drainage, which means obstruction--opposition to the requirements of nature--for one of the functions of the mucous membrane is to secrete and this secretion must have an outlet or the part becomes diseased.

The micro-organisms are present wherever there is life and are as necessary to life as they are to death.

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