Appendicitis

Appendicitis, the modern medical term for inflammation of that part of the intestine which is known as the “appendix.” Though not a new disease, there can be no doubt that it is far commoner than it used to be, though the explanation of this increased frequency is not yet forthcoming. Amongst the virulent micro-organisms associated with the disease no one specific germ has hitherto been found. It may be remarked that the theories that influenza, or the use of preserved foods, may be connected with the disease as cause and effect, have supporters. Sometimes the disease is due to the impaction of a pin, shot-corn, tooth-brush bristle, or fish-bone in the appendix, which has set up inflammation and ulceration. In many cases a patch of mortification with perforation of the appendix is caused by the presence of a hard faecal concretion, or “stercolith,” which from its size, shape and appearance has been mistaken by a casual observer for a date-stone or cherry-stone.

Apart from the fact of the more frequent occurrence of appendicitis, the disease is now better understood and more promptly recognized. It was formerly included under the term “perityphlitis”—that is, inflammation connected with the caecum or blind portion of the large intestine. But in the vast majority of cases the inflammation begins in the appendix, not in the intestine proper. It is apt to extend and set up a localized peritonitis, which in the worst cases may become general.

Appendicitis is more often met with in the young than the old, and in boys rather than girls; and in some families there is a strange predisposition towards it. It is often started by a chill, or by over-exertion, and sometimes the attack follows a blow or strain, or some other direct injury, after which the virulent micro-organisms seize on the mucous membrane and involve the appendix in acute inflammation.

The appendix is a narrow tube, about the size of a goose-quill, with an average length of 3 in. It terminates in a blunt point, and from its worm-like shape is called vermiformis. It is an appendage of the large intestine, into which it opens, and is regarded as the degenerate relic, surviving in man and other mammals, of an earlier form of intestine. Foreign bodies passing down the intestinal canal may find their way into the appendix and lodge there. Frequently the diseased appendix is found blocked by hard faeces or undigested particles of food, such as nuts, fibrous vegetable matter, and other imperfectly masticated substances; inflammation may occur, however, without the presence of any impacted material. The appendix may be twisted, bent, or otherwise strangulated, or its orifice may be blocked, so that the tube is distended with mucus which can find no outlet; or ulceration of tuberculous or malignant origin may occur. Inflammation started in the appendix is liable to spread to the peritoneum, and herein lies the gravity of the affection and the indication for treatment. The symptoms vary from “indigestion,” and slight pain and sickness, which pass off in a few short days, to an exceedingly violent illness, which may cause death in a few hours. Pain is usually first felt in the belly, low down on the right side or across the region of the navel; sometimes, however, it is diffuse, and at other times it is scarcely complained of. There is some fever, the temperature rising to 101° or 102° F., with nausea, and very likely with vomiting. The abdomen is tender to pressure, and the tenderness may be referred to the spot mentioned above. Some swelling may also be made out in that region. The attack may last for two, three or four days, and then subside. There are, however, other cases less well defined, in which the mischief pursues a latent course, producing little more than a vague abdominal uneasiness, until it suddenly advances into a violent stage. In some chronic cases the trouble continues, on and off, for months or even for years.  
  
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Large Intestine showing Vermiform Appendix (v.a.) and Caecum (c).  
  
On paper it is easy to arrange cases of appendicitis into three classes—catarrhal, ulcerative and mortifying—but in actual practice this is neither desirable nor possible. Such classification is based upon the symptoms, and in appendicitis symptoms may be actually misleading. The three conditions to which the surgeon chiefly looks for guidance are the aspect of the patient, the rate of his pulse and the degree of fever as shown by the thermometer. 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. Unfortunately, the surgeon can no more tell what he is going to find at his operation in some of these cases than he can foretell the course which any particular case is going to run.

We may most usefully give here the symptoms as they are likely to be found in an ordinary case of appendicitis, and as they may be observed by one who is not a member of the medical profession, in a way that may prove helpful to him when circumstances have awakened his interest in the disease.

The case taken shall be that of a boy at school, for, as already stated, boys are more prone to the disease than girls. The boy has had, may be, occasional attacks of “indigestion” which have duly passed away under the influence of aperient medicines, and, being heated at play, he has sat down upon the cold ground. Or he has got wet through or over-tired during a long walk or ride. At any rate, his vital powers have been suddenly lowered, and the micro-organisms teeming in his bowel have seized upon the lining membrane of the appendix. He feels out of sorts, and if he manages to eat a meal he very likely vomits it soon after, for the whole nervous system of his abdomen is disturbed by the local inflammation. The act of vomiting gives slight relief, however, and probably he begins to complain of pains in his head as well as in his abdomen, and possibly he has an attack of shivering—the result of disturbance of his general nervous system. By this time he may be attacked with intense pain in the part of his abdomen a little above the middle of the right groin, and at that spot there may be a tenderness, and a feeling of resistance may be made out by the gentle pressure of the finger. In order to relax the pressure upon the tender area he probably lies with his right thigh slightly bent. By this time he may look ill, his face being slightly flushed, or pale and anxious. If the clinical thermometer is placed under his tongue, the index may rise a degree or two, perhaps several degrees, above normal, and his pulse may be quickened to 90 or 100 beats a minute. Perhaps it is a good deal quicker than this. Later, the skin of the lower part of the right side of the abdomen may be flushed or reddened.

This clinical picture leaves no room for doubt. The boy has an attack of acute septic inflammation of his appendix. Let it be that the symptoms have come on quickly, and that the affection is not more than ten or twelve hours old; no one can tell precisely what course the disease is going to run. It may be that with rest in bed, constant fomentations, and absolute starvation, the inflammation will subside; but it is just as likely that in spite of this judicious treatment the symptoms will go from bad to worse, and that a belated operation will fail to rescue the boy from a general peritonitis which may end fatally. But at present, so far as one can tell, the disease is still limited to the appendix. And what, at this moment, is the best line of treatment? Some practitioners would answer—“Let the acute attack settle down, and then, after a week or ten days, when everything is quiet, remove the appendix, for statistics show that when the operation is done in the quiet interval the results are extremely favourable, whilst if it is done in the acute stage the outlook is not so bright.” This is quite right. But one cannot be sure that the “quiet interval” will ever arrive. The case in question may be one of those which rapidly go on from bad to worse, and mortification and perforation of the appendix having taken place over some hard faecal concretion, general peritonitis is inevitable, with distension of the bowel and hopeless blood-poisoning. 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. It is highly probable that if every available hospital surgeon were asked if he had ever had cause to regret having advised early operation in a case of appendicitis the answer would be “No”; on the other hand, every surgeon would be able to recall cases in which delay had been followed by disaster—which an early resort to operation would, in all probability, have prevented.

If the disease is going to assume the severe form, all the symptoms, as a rule, increase in severity. The facial expression becomes more anxious, and the accumulation of gas in the paralysed intestine causes an increase in the abdominal distension, so that the patient lies with his knees drawn up. The vomiting continues. The pulse quickens to 120 or 140 a minute, and the temperature rises, perhaps to 104° F. The swelling and tenderness increase on the right side of the abdomen, and if the abscess does not find escape externally it probably bursts into the general peritoneal cavity, and the patient becomes bathed in profuse sweat, the result of blood-poisoning. Death is likely to follow within two days, the result of blood-poisoning and exhaustion.

Catarrhal and Relapsing Appendicitis.—Some cases of appendicitis run a mild course, giving rise to no worse symptoms, perhaps, than those of “indigestion” and nausea, with a feeling of general discomfort in the abdomen, and, probably, some local tenderness. The attack may be preceded or accompanied by constipation. The administration of a mild aperient or an enema, rest, starvation and fomentation will probably put matters right again—at any rate for a time.

This form of the disease may be due to the presence of “bolted,” unchewed or indigestible food in that part of the large intestine into which the appendix opens. And these mild recurrent attacks may sometimes be got rid of altogether by having the teeth put in order, and by inducing the individual to choose his food with discretion, to chew it carefully, to take his meals regularly and to eat slowly.

Obviously, these attacks are very different from those of the acute septic form of the disease described above, though there is no telling that one of them may not develop into the acute form. Some of the mild attacks are due to a kink in the appendix, or to some other condition which temporarily prevents the secretions of the appendix from finding their way into the large intestine. Others of them are caused by a passing catarrhal inflammation of the lining of the appendix and have a distant resemblance to a recurring “sore throat.”

After undergoing one or two of these mild attacks the patient would be well advised to have his appendix removed when it has once more got into the “quiet stage.” Experience abundantly shows that the operation can then be performed with but slight disturbance of the patient, and with the smallest possible amount of risk. 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. 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.

As regards treatment, the greatest safety consists in the prompt removal of the inflamed appendix, and statistics show that if the operation can be done in the first or second day of even an acute attack, the result is generally favourable—that is to say, if the appendix can be removed whilst the disease is still shut up within its tissues. But in some cases ulceration and perforation, or mortification, may have taken place over a hard faecal concretion within the first twenty-four or forty-eight hours, and, the septic germs having been let loose, peritonitis may have already set in, and operation may be followed by disappointment. Still, if the case had been left unoperated on, no other result could have been expected. It was not to the operation, but to the intensely acute disease that the calamity must be attributed.

Nature is marvellously clever in some of these cases in shutting off the area of the disease by glueing together the neighbouring coils of intestine, the limited local peritonitis causing the tissues to build themselves into a wall which securely shuts in the abscess cavity. But in other cases she seems helpless, no barrier being formed for limiting the area of disturbance. In such a case it is inevitable that disappointment must result from the surgeon delaying operation in the hope that delimitation might take place. And when at last he makes his incision he sees that the disease has had so long a start that his own chance of success is but a poor one. In a less severe attack, under the influence of rest, starvation and fomentation, and in cases of chronic and of relapsing disease, the surgeon may watch and wait and choose his own time for operating. But when the symptoms are steadily increasing in severity he should urge an immediate incision. When, as often happens, the inflammation begins suddenly and severely, and, under the influence of treatment, steadily quiets down, the surgeon does well to delay operation. But in a fortnight or so, when everything has become once more quiet, he will urge the removal of the appendix, for this one attack is more than likely to be the forerunner of other attacks if the diseased appendix is left.

The most serious cases are those in which the aspect, the pulse, and the temperature of the patient fail to give warning of a very advanced state of disease. Every surgeon of experience has met with cases in which, though there is nothing pointing to the fact that the patient is on the brink of a disaster, the operation has shown that the appendix is mortified, and that it is surrounded with abundant foul matter. It is then that he regrets not having operated a day or two earlier. Consequently it is a good rule to operate in all doubtful cases. In cases in which one happens to know that previous attacks have passed off under palliative treatment, there is no need for immediate operation; the quiet interval may be safely waited for. But in cases in which there is “no history,” and in which the surgeon has nothing to guide him, the greatest safety is in prompt operation.

If an attack of acute appendicitis is allowed to take its course unoperated on, abscess forms in the peritoneal cavity in the region of the appendix, but if already inflammation has happily glued the intestines together around that area, the pus is confined within definite limits. But as the abscess increases in size the demand for its evacuation becomes urgent. The pus, under the influence of a natural law, seeks its escape by the path of least resistance; sometimes this is into the intestine, and occasionally into the bladder. The most satisfactory course which it can take is through the wall of the abdomen and out above the right groin. As it is making its way in this direction the skin over that part becomes red, swollen, hot and tender, and the tissues between it and the skin become swollen and brawny. Rarely is fluctuation to be made out until the pus has worked its way close to the surface. Later, ulceration takes place in the undermined skin, and the stinking contents of the abscess escape, greatly to the relief of the patient. But long before this could happen the surgeon should have made an incision through the inflamed tissues in order to give nature some greatly needed help. For in many cases she allows the pus blindly to discover that the course of least resistance is not towards the surface of the abdomen but through the inflammatory barrier formed by the adherent coils of bowel, and so into the general peritoneal cavity. This unfortunate issue may give temporary relief to the patient, so that he says that he feels much better, and that his pain has nearly gone. But though his temperature may fall, his pulse is apt to quicken—an ominous coupling of symptoms; the paralysed bowels become further distended, so that the lungs are pressed upon and breathing is embarrassed; hiccough comes on; and whether operation is now resorted to or not, a fatal end is highly probable. In other cases, the escaping pus finds its way up towards the liver and forms an abscess below the base of the lungs.

If operation is performed when appendicitis has run on to the formation of abscess, and the diseased appendix presents itself, it should of course be removed; but if it does not present itself the surgeon should abstain from making a determined search for it, as in so doing he may break down the barrier which nature has provided, and thus himself become the means of spreading a septic peritonitis. Nor should he attempt to make clean the foul abscess cavity. All that he should do is to provide for efficient drainage. A large proportion of these cases do extremely well with incision and drainage, and in the subsequent healing of the cavity the wreckage of the appendix either undergoes disintegration or is rendered harmless for further anxiety.

In some cases, however, the damaged appendix remains as a smouldering ember, ready at any moment to cause further conflagration. This is made manifest by lingering pains, and by tenderness and warnings after the abscess has healed, and the patient will be well advised to have what is left of the appendix removed by operation at a time of quiescence. The operation, however, may turn out to be a very difficult one. Sometimes the wound by which the abscess has been evacuated, by nature or by art, refuses to heal completely, a little discharge of a faecal odour continuing to escape. The small wound leads into a faecal fistula, and a bent probe passed along it would probably find its way into the bowel. The wound is likely to close of itself in due course; but if after many weeks of disappointment it still continues to discharge, the surgeon may advise an operation for its obliteration.

It occasionally happens that after operation the scar of the wound in the abdominal wall yields under the pressure from within, and a bulging of the intestines beneath the skin occurs. This is called a ventral hernia, and if the patient cannot be made comfortable by wearing a truss with a large flat pad, an operation may be deemed advisable.

If, in a case of appendicitis, for one reason or another operation is to be delayed, what treatment should be resorted to? The patient should be put to bed with his knees resting over a pillow, and a large fomentation under oil silk should be laid over the lower part of the abdomen. No food should be given beyond an occasional sip of hot water. Purgatives should not be administered, as this would be to set in movement an inflamed piece of bowel. If the case is not acute, a large enema of soap and water with turpentine may be given, or, possibly, a dose of castor oil by the mouth. As a rule, however, it is unwise to set the bowels in vigorous action until the diseased appendix has been removed. No opium should be given.

Acute intestinal obstruction, cancer of the intestine, inflammation of the ovary, typhoid fever and renal and gallstone colic, are affections which are apt to be mistaken for appendicitis. The first of these resembles it most closely, and diagnosis is sometimes impossible without resort to operation. And it is a fortunate thing that, when error of diagnosis has been made, the operation which was designed for dealing with an inflamed appendix may be directed with equal advantage to the morbid condition which is found on opening the abdomen. In typhoid fever the characteristic temperature, the general condition of the patient, and the presence of delirium are differentiating signs of importance; in renal and gallstone colic the situation and the more paroxysmal character of the pain are usually distinctive.

(E. O.*)

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