Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 1

Appendicitis: The Etiology, Hygenic and Dietetic Treatment.

by John H. Tilden, M.D.

CHAPTER I.

This cut represents the back view of the cec.u.m, 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 cec.u.m; 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 cec.u.m is, 2. The ileum, 6, opens into the cec.u.m, all of the bowel below the opening being cec.u.m, the opening of the appendix, 3, is in the lower part of the cec.u.m.

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, inv.a.g.i.n.ation 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 embarra.s.sing, to foregone conclusions; hence pains in obscure and foreign parts took on great importance when a.n.a.lyzed 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 uns.e.xing of the entire female population. The ovaries had the reputation of causing all the trouble that the flesh of woman was heir to. Ooph.o.r.ectomy 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 a.s.sociations 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.

*(Editor's note: "A Stuffed Club" was the newsletter or journal published by Dr. Tilden for many years.)

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 appet.i.te, 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 cec.u.m. 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.

CHAPTER III

_Etiology: _To understand the cause of appendicitis we must go back to the beginning, and when we do we find that it starts just where all diseases start, namely, _where health leaves off! _When the laws of health are broken for the first time, it can be said that the individual has started on the road of ill health. How fast he will travel and just what will be the character of the disease he meets with will depend upon his const.i.tution, inheritance, environment and education. I do not mean by education, school or book education; I mean intuition--that knowledge which evolves from home life and habits. I mean, has he any self-discipline? Does he know anything about self-denial? Has he any conception of a control higher than impulse? Has he been brought up to know that there is a limit to the gratifying of wants and desires beyond which, if he goes, he must make good with laws that are as exacting as they are invariable?

Does he know that nature shows no favoritism? Does he know that there are laws regulating his intercourse with men--with everything--that exact absolute justice from him? And that, if he takes advantage of weakness or ignorance because he can, or if he secures an advantage through credulity or trickery, he must settle for the crime before a judge who is absolutely just! If he has this education, which is a const.i.tutional ingrafting from the mother's blood, fructified by a like potential father, he will be almost immune from all diseases. This is an education that can not be secured unless the individual has the prenatal and environing influences to differentiate these static attributes of his nature, and, if he has, the result will be that all these qualities will come to him because "like attracts like." In an atmosphere where others attract evil this individual attracts good. The same is true on the physical plane. Those who have diseased bodies always have disease making habits, hence they attract from a given environment all the disease making impulses, while those of healthy bodies have health imparting habits, and attract from the same environment the health impulses for which they have an affinity.

The const.i.tution, 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 cla.s.s 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, b.u.t.ter, 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 cec.u.m. 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 cec.u.m, for the colon is loaded with fecal acc.u.mulations so that the onrus.h.i.+ng contents of the small intestine can not be received by the colon; hence the force of the whole peristaltic impact is spent on the cec.u.m, which must endanger the integrity of the mucosa as well as the musculature.

This point of the bowels, the cec.u.m 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 overcrowding of metabolism, as explained above, the chronic constipation and toxic bowel secretions, I recognize as the chief factors--the necessary and leading factors--in the building and maintaining of that const.i.tutional state which I am pleased to denominate _Const.i.tutional Catarrh. _When this state is established, it can be said that the individual is ready to develop any phase of disease that circ.u.mstance, accident, or caprice of fortune or environment may offer.

The constant presence of gas in the bowels becomes more and more menacing to the cec.u.m as the constipation increases. The filled-up condition of the bowels--the colon and r.e.c.t.u.m--prevents the easy pa.s.sage of gas from the bowels, hence it acc.u.mulates in the ileo-cecal region and keeps the cec.u.m distended.

The constant dilating of the cec.u.m from gas acc.u.mulations and the forced dilations from diarrheas made either from drugs or irritating foods, must not only damage the cec.u.m 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 const.i.tutional 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 cec.u.m and the appendix, and their relation to other parts. The cec.u.m is a large, blind pouch, one of the shortest of the several divisions in the continuity of the intestinal ca.n.a.l, 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 cec.u.m, the force of gravity must be reckoned with.

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