Since the late eighties, medicine has always regarded appendicitis as a purely surgical condition, and appendectomy as the only effective treatment.
Earlier observers had for some time been describing a condition of catarrh and various degrees of inflammation of the vermiform appendix under the title of typhlitis and perityphlitis, and a few had recognized the rupture of the appendix as a probable cause of the widespread peritonitis that had proved so unmanageable and so fatal.
Alonzo Clark adopted the splint idea in treatment of all inflammations of the general abdominal peritoneum, his idea being opium to the point of tolerance with respiration at twelve per minute as a guide to the degree of narcotism. His treatment showed a lowering of the death rate in general peritonitis from seventy-five to twenty-five per cent.
However, even this did not approach the constructiveness that must be necessary before any treatment can be said to be wholly beneficial, and his results left peritonitis still a most unmanageable condition.
Some surgeon, whose name at the present moment escapes me, devised the removal of the vermiform appendix as a radical cure, but whether we can call a removal of an organ “cure”, or whether it is a vandalism depends on our point of view. To remove a diseased organ is surely not to cure that organ, but its removal does hide the evidence of that particular type of disease.
Since this time appendectomy has come to be considered the only means of combatting this too frequent diseased condition.
As to the frequency of occurrence of all types of appendicitis and the effect on mortality statistics we can quote from a rather recent article by Frederick L. Hoffman, perhaps the leading insurance statistician of our time.
He called attention to the fact that deaths from appendicitis had been rising rather steadily ever since we knew what appendicitis was, and the disturbing factor to him was that deaths from the condition had practically all had operative histories. His argument was that if operation is the only treatment, and if this has not yet succeeded in lowering the death rate from the condition, how long would it be till life rates would be compelled to rise through operation of this one cause? Speaking from the insurance standpoint of indemnities only, he was alarmed over the outlook. Then what of the public, which furnishes the diseased appendices?.
Hoffman is an insurance statistician, and not an alarmist, and he is in the habit of thinking only in fingers, not speculating on health conditions.
That appendicitis is on the percentage increase there is no doubt; and there is less doubt that the death rate, also rising in percentage figures, has not only not been influenced favorably by our universal operative treatment, but it is hard to escape the conviction that the surgical treatment of this condition is adding seriously to mortality figures.
Now let us consider this little organ, the appendix, from the standpoint of its anatomy and physiology.
To begin with, it is but a part of the caecum, a little glove- finger-shaped organ whose lumen is continuous with the caecal mucosa, subject to the same catarrhs as the contiguous mucous surface lining the caecum. In the next place we have to recognize the almost universal character of colitis in some degree, from transient constipation to diarrhoeas and all the degrees of fermentation and putrefaction that we know are occurring continually in the average caecum.
It is scarcely thinkable that this catarrhal condition will not spread through continuity of mucous surface to the appendix; and here we are confronted by a different symptom complex, on account of the structural differences in the two closely related organs. In the case of the caecum we have free drainage through the ascending colon, for the lumen is large, and obstructions can scarcely occur without external pressure of adhesions or growths.
The appendix with its small lumen, and its contraction of this at the point of attachment to the caecum, needs to swell but little to completely occlude its orifice, so it has difficulty in drainage if it is at all catarrhal or inflammed.
The material filling the lumen of the appendix is a part of that filling the caecum, and if we have fermentation and putrefaction in the colon we have the same condition in the appendix, and necessarily so.
Fermentation and putrefaction both result in gas formation, and with the appendicial valve closed and egress of gas interfered with, we can have nothing less than painful distention of the appendix, accounting for the familiar pain of appendicitis. I have seen but one case operated on during this stage of intense pain, and in this case the appendix was distended to what looked like impossible dimensions, being as large as the surgeons thumb. Ligation of the valve region of the appendix was done first, then the surgeon pricked the point of the appendix with his knife and the gas actually whistled when escaping, leaving the organ in a state of complete collapse or of normal size.
Now when this occurs apart from operative treatment, one of two things has to happen; either the pressure becomes so high as to force escape through the valve into the caecum, or the swelling subsides sufficiently to permit of this, or else rupture occurs, with the fulminant type of so-called pus appendicitis. Surgeons expect to lose twenty-five per cent or more of this type, general peritonitis accounting for the very large death rates following rupture.
However, nature is most kind in his particular and anticipates this rupture or the more gradual ulcer that permits of a leak of the appendicial contents into the free peritoneal cavity. As soon as perforation is even threatened the intestines glue themselves together about the inflamed area, creating a barrier against general peritoneal infection, as witness the mass by which we recognize a perforated or ruptured appendix.
If this mass can be made out by palpitation it is evidence that the condition is already taken care of, the infected area walled off completely, and general peritonitis obviated. It is unthinkable that nature can instantly create this wall of adhesions and at the same time be unable gradually to insure the potency of this barrier against spread of the peritoneal inflammation.
In the acute unruptured case, relief is easily obtained in one to two hours by complete emptying of the colon by means of high- colonic irrigations or the repetition of the plain simple two- quart enema till the water returns clear.
Immediately the appendix is inflamed there is complete stasis of peristalsis at this point, and positively no danger is present even if water is forced into the colon from considerable heights, as in placing the bag five feet above the hips, though three feet elevation will usually serve to introduce the water without too much pressure.
It is a rare case in which relief is not quite complete in one or two hours, and not infrequently by the time the third or fourth enema is given there is no longer any pain.
Soreness of the appendicial region may persist for one or two days, but the recovered patient is generally at work next day as usual with no bad after-effects.
Should pain still be excessive after the colon is well emptied, it is only necessary to keep the patient in bed on the back with the knee well elevated an an ice bag over the region of pain, unless this pain should be at some distant and seemingly unrelated point, as not infrequently happens. However, every physician is familiar with the location of McBurneys Point, and if doubt arises, the location will be found easily by a little deep pressure.
Should rupture have occurred, or perforation, with the familiar mass in the lower right quadrant of the abdomen, the very same procedure is all that is required; but in all cases, absolutely no food should enter the digestive tract till recovery is complete; and in the case of perforated or ruptured cases there will be no desire for food of any kind, as the entire digestive tract is out of function.
Treated as above, appendicitis becomes one of the shortest and simplest of the acute manifestations of disease, for it subsides rapidly when the causative factors have in this way been discontinued.
During the writers first sixteen years of practice he continued to think of appendicitis as one of those accidental happenings for which there is no known remedy; but for the past twenty-nine years he has pursued the above simple attack on this supposedly surgical condition without one adventitious result to cause doubt of the correctness of the methods used.
Well over four hundred cases of all types of appendicitis have been treated in this simple way, without one fatality to mar the statistics, including twenty-four perforated cases with well- defined abscess wall, all of which drained naturally into the colon and were at work in one or two days after this spontaneous cure. With two exceptions, all of these cases matured and drained within forty-eight hours; in the two exception the time was five and seven days.
