Appendicitis, in these days, is one of the most frequent causes of an unexpected death. As this work is designed to set forth the means by which we may prolong life, it is desirable not to miss the opportunity of offering a few remarks, in connection with the chapters on the preservation of the intestinal functions, upon the cause and prevention of an intestinal disease by which particularly young and promising lives are frequently cut off.
In the previous chapters we saw that the cæcum was one of the places of selection for the stagnation of the fæcal contents in the intestinal canal. As the pressure of such fæcal matter in the cæcum and colon is greatest toward the appendix the contents may go more easily into than away from the appendix, and particularly so when, from a long rest in the cæcum, they are thickened. The return of fæcal matter from the appendix is often hindered by a spindle-shaped thickening at the junction of the appendix with the cæcum, which presents the appearance of a narrow bridge.
This thickening of the mouth of the appendix is the consequence of the very close contact of the psoas muscle, upon which, in many people, the appendix lies, so to speak resting upon it. This has been shown by Offerhaus[219] (a surgeon in the Hague Hospital) to be the case in 62 per cent. of normal men.
In certain movements, such as running or cycling, the psoas is continually pressing against the appendix, and it is natural that such continuous pressure against this organ will in time leave a permanent mark, which is, indeed, seen in many cases of appendicitis. After a certain time a circumscribed segmentation will be visible on the parts of the appendix which are in contact with the psoas, and later this becomes so marked that a circular kinking results, establishing the narrow bridge to which we have already referred.
It is logical that the thicker the appendix, the more pronounced will be the marks produced by the pressure of the psoas. The average size of the appendix, even in the adult, is that of a somewhat slender worm, from which is derived the name “vermiform appendix.” But when there is stagnation of the fæcal contents in the appendix, and especially when the thickened fæcal matters are of such hard consistency that a hard stony concrement, such as the coprolith is formed, then the appendix sometimes assumes quite a comparatively large size. We saw the case of a girl of 16, operated on by Dr. Offerhaus at the Hague (details of which case were published by him), in whom the appendix was of the size, in circumference, of a large thumb.
In such large appendices the marks of the psoas will, of course, be more pronounced, and frequently the narrow bridge referred to will develop. This is caused by the appendix being further attached to the intestines where, owing to the narrow connecting bridge, it is unable to evacuate itself, and so grows larger and larger, the mischief thus constantly increasing.
It is also evident that the nutrition of an organ whose blood-supply is mechanically interfered with, as in the case of the appendix by its close contact with the psoas, as described above, must necessarily be a precarious one; and it is a pathological fact that an organ which is badly supplied with blood is also more liable to disease, because the insufficient supply of blood causes a diminution in the number of phagocytes thereby weakening the defense of the organ against infection, as explained in Chapters III and X. Consequently the microbes easily prevail, particularly in a portion of the body like the intestines, where they normally exist in such great numbers.
By the foregoing we have not only shown the cause, but also the principles for a rational prevention, of appendicitis. As we have seen, the starting point of all mischief is the close proximity of the psoas to the appendix, and the occasional cause is constipation, with stagnation of the fæcal contents. The best preventive against appendicitis consists in avoiding both causes, which, however, is only possible in the latter case by adopting all those measures we have mentioned in the chapter on the treatment of constipation.
The first cause, the close contact of the psoas with the appendix, can certainly not be prevented; but what we can do is to avoid all movements by which the psoas is unduly pressed against the appendix. This can be done by avoiding those exercises in which the psoas is brought into frequent contraction and then pressed forcibly against the appendix: for instance, running, cycling, etc. The young lady, already referred to, with the large stone in the appendix, indulged freely in such sports. The habit of sitting with one leg crossed over the other should also be avoided.
We must now, however, determine who those persons are in whom such a condition exists. They are those who frequently complain of pains in the appendicular region, usually after quick walking or running, and especially after cycling, and at times even without these; but in this latter class the pain is milder. In order to make an exact diagnosis whether such pains are caused by pressure of the psoas upon the appendix, we must tell the patient to lift the right leg high and we then press with the right hand against the thigh. If there is a latent form of appendicitis due to the above-named anatomical relations, then the patient will experience pain when we press with the left hand upon McBurney’s point. By this means appendicitis can be diagnosed while it is still in an early stage, and the life of many may be saved before it is too late, and we know only too well how rapidly this treacherous disease can lead to a premature death.
Having made the diagnosis in the above-mentioned way, we should prohibit all active movements, especially running, cycling, etc., and take special care to have a daily bowel movement by the use of a suitable diet and those other means previously mentioned.
Pain in the appendicular region may be of a very pronounced character, and yet there may be no appendicitis, for it may be caused by inspissated fæces. The presence of stagnating fæcal matter often induces the formation of gas, and by the distention so caused the intestinal nerves are irritated and thus pain occasioned.
We can distinguish between appendicitis and pains following colics, caused by flatulency, by giving carminatives, such as the decoction of different carminative herbs called Aqua Carminativa Regia, which is much used in Germany and Austria, where it is an official preparation of the Pharmacopœia Austrica and Germanica. A few tablespoonfuls of this decoction will produce free passage of gas, after which, in the case of flatulent colic, the pain will disappear, especially if we add a purgative and clear the intestines. Of course, in appendicitis the pain will not disappear after the use of carminatives.
Besides the foregoing very frequent causes of appendicitis there are a few others to deal with, all of which here is out of the question; our intention is to confine ourselves to mentioning some of the more frequent causes and not to deal exhaustively with the subject, which can be found in the various hand-books on surgery. Yet we should like to mention one cause that is not infrequent, and this deals with the relation between the tonsils and the appendix. If we examine these organs histologically, we shall find that both are of the same lymphoid tissue, and, indeed, some writers go so far as to term the appendix the tonsil of the intestine.
Now we can often observe that when one of the lymphoid structures is changed, the others may follow; and this shows that just as the ductless glands are in close relation to one another, so also the ductless glands and the lymphoid structures stand in close mutual connection, as we have mentioned in previous works, emphasizing the fact that the tonsils are often much enlarged in myxœdema, Graves’s disease, acromegaly, diabetes, etc.
In addition to these intimate relations there are also other causes arising from the tonsils that affect the appendix. Such is the case when the tonsils are inflamed and infectious matter arising therefrom reaches the intestines. The cause of appendicitis from such a source has been confirmed by the bacteriological examinations of Professors Lanz and Tavel. Indeed, clinically, we can often see that appendicitis has been, in quite a number of cases, the result of previous tonsillitis, this in turn often being caused by the secretion from the inflamed posterior part of the nose coming in contact with the tonsils, as has been previously stated.
Very frequently such a condition exists in conjunction with adenoid vegetations, and this explains the error into which Delcour has fallen in his book on the relation of adenoid vegetations to appendicitis, in which he attributes the immediate cause of the latter to a state induced by an insufficiency of the thyroid gland. We can often observe that adenoid vegetations can exist with a good thyroid and vice versâ, although we cannot deny the fact that in children with thyroid insufficiency adenoid vegetations are frequent.
It is very probable that the first mentioned causes of appendicitis and the last named often go together, the one assisting and developing the other. The unfavorable anatomical position and constipation, together, offer a very favorable soil in which, through bacterial co-operation after tonsillitis, influenza, or other infectious diseases, this much dreaded disease can develop.
By a slight operation life is often saved. The pity is that such aid is often invoked too late.