Part 14 (1/2)
This dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these ”foreign bodies” were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous ma.s.ses of the faeces.
We are in a nearly similar position in regard to the third alleged cause of appendicitis, and that is food. Many are the accusations which have been made in this field. On the one hand, meat and animal foods generally have been denounced, on account of their supposed ”heating” or ”uric-acid-forming” properties; while on the other, vegetables and fruits have been equally hotly incriminated, on account of their seeds, fibres, husks, and irritating substances, and the danger of their being contaminated by bacteria and other parasites from the soil. These charges appear to have little adequate foundation, and, so far as we are in a position now to judge, the only way a food can give, or be accessory to, appendicitis is by its being taken in such excessive amounts as to set up fermentive or putrefactive changes in the alimentary ca.n.a.l, or by its being in an unsound, decaying, or actually diseased condition. Any amounts or quality of food which are capable of giving rise to an attack of acute indigestion may secondarily lead to an attack of appendicitis. The only single article of diet whose ingestion is declared by Osler to be rather frequently followed by an attack of appendicitis is the peanut.
Therefore, the best thing to do in the way of taking precautions against the occurrence of appendicitis is, in the language of the day, to ”forget it” as completely as possible, rea.s.suring ourselves that, in spite of its extraordinary notoriety and popularity, it is a comparatively rare disease in its fatal form, responsible for not more than one-half of one per cent of the deaths, and that the older we grow, the better become our chances of escaping it.
Whatever we may have decided in regard to our brains, by the time we reach fifty, we may feel reasonably sure we've no appendix.
But the question will at once arise, if the appendix be so tiny in size, so insignificant in capacity, and so devoid of useful function, what is the use of disturbing ourselves over the question of what may become of it? If it is going to decay and drop off, why not permit it to do so, with the philosophic indifference with which we would sacrifice the tip of our little fingers in a planing-mill? Here, however, is just the rub, and the fact that gives to appendicitis all its terrors, and to the question of what to do in each particular case its difficulties and perplexities.
The appendix does not, unfortunately, hang out from the surface of the body, where it could peacefully decay and drop off without prejudice to the rest of the body, or be quickly lopped off in the event of its giving trouble. On the contrary, it projects its stubby and insignificant length right into the midst of the most delicate and susceptible cavity of the body, the general cavity of the abdomen, or peritoneum. The thin, sensitive sheet of peritoneum which lines this cavity covers every fold and part of the food-tube, from the stomach down to the r.e.c.t.u.m. And when once infection or inflammation has occurred at any point in it, there is nothing to prevent its spreading like a prairie fire, all over the entire abdominal cavity from diaphragm to pelvis. If this wretched little remnant were a coil of explosive fuse within the brain-cavity itself, which any jar might set off, it could hardly be richer in possibilities of danger.
A redeeming feature of appendicitis is that the appendix lies--so to speak--in a corner, or wide-mouthed pouch, of the great peritoneal cavity; and if the inflammation set up in it can be ”walled off” from the rest of the peritoneal cavity, and limited strictly to this little corner or pouch, all will be well. This is what occurs in those cases of severe appendicitis which spontaneously recover. If, however, this disturbance bursts its barriers, and lights up an inflammation of the entire peritoneal cavity, then the result is likely to be a fatal one.
Just how far nature can be trusted in each particular case to limit and stamp out the process in this manner is the core of the problem that confronts us, as attending physicians.
In the majority of cases, fortunately, the peritoneal fire brigade acts promptly, pours out a wall of exudate, and locks up the appendix in a living prison, to fight out its own battles and sink or swim by itself.
But unfortunately, in a minority of cases, by a wretched sort of ”senatorial courtesy” which exists in the body, the appendix is given its ancestral or traditional rights and allowed to inflict its petty troubles upon the entire abdominal cavity, and include the body in its downfall.
Lastly come the two most pertinent and appealing questions:--
What is the outlook for me if I should develop appendicitis? And what is to be done?
In regard to the first of these, it is safe to say that our answer is much less alarming than it was in the earlier stage of our knowledge.
Naturally enough, in the beginning, only the severest and most unmistakable forms of the disease and those which showed no tendency to localization, were recognized, or at least came under the eye of the surgeon; and as a large percentage of these resulted fatally, the conclusion was reached, both in the medical profession and by the laity, that appendicitis was an exceedingly dangerous disease, with a high fatality in all cases. As, however, physicians became more expert in the recognition of the disease, it was discovered to be vastly more common, while side by side came the consoling knowledge that a considerable percentage of cases got well of themselves, in the sense of the inflammation being limited to the lower right-hand corner of the abdominal cavity, though, of course, with the possibility of leaving a smouldering fuse which might light up another explosion under any stress in future.
Further, as the attention of the post-mortem investigators at our large hospitals was directed to the subject, it was found that a very considerable percentage of all bodies, ranging from twenty to--according to some estimates--as high as sixty per cent, showed changes in the appendix and its neighborhood which were believed to be due to old inflammations; so that, while it is possible to speak only with great caution and reserve, the balance of opinion among clinicians and pathologists of wide experience and the more conservative surgeons appears to be that from one-half to two-thirds of all cases of appendicitis will recover of themselves, in the sense of subsiding more or less permanently, without causing death.
On the other hand, it must be remembered that the appendix is an organ which, so far as any evidence has been adduced, is entirely without useful function; that it is in process of shriveling and disappearance, if left entirely alone, and that the best result which can be expected from a self-cured attack of appendicitis is the destruction of the appendix and its elimination as a further possible cause of mischief. By avoiding an operation in appendicitis, we may be practically certain that we save nothing that is worth saving--except the fee. Moreover, even though only from one-fourth to one-third of all cases develop serious complications, you never can be quite sure in which division your particular case will fall.
The situation is in fact a little bit like one related in the experience of Edison, the inventor. The trustees of a church in a neighboring town had just completed a beautiful new church building with a high spire, projecting far above any other building in the town. When it was nearing completion, the question arose, should they put on a lightning-rod. The great church itself had strained their financial resources, and one party in the board were of the opinion that they should avoid this unnecessary expense, supporting their economic att.i.tude by the argument that, to put on a lightning-rod, would argue a lack of trust in Providence. Finally, after much debate, it was decided, as the great electrician was readily accessible, to submit the question to him. Mr. Edison listened gravely to the arguments presented, pro and con.
”What is the height of the building, gentlemen?”
The number of feet was given.
”How much is that above that of any surrounding structures?”
The data were supplied.
”It is a church, you say?”
”Yes.”
”Well,” said the great man, ”on the whole, I should advise you to put on a lightning-rod. Providence is apt to be, at times, a trifle absent-minded.”
The chances are in favor of your recovery, but--put on a lightning-rod, in the shape of the best and most competent doctor you know, and be guided entirely by his opinion. An attack of appendicitis is like shooting the Grand Lachine Rapids. Probably you will come through all right; but there is always the possibility of landing at a moment's notice on the rocks or in the whirlpools. With a good pilot your risk doesn't exceed a fraction of one per cent. And fortunately this condition has been not merely theoretically but practically reached already; for the later series of case-groups of appendicitis treated in this intelligent way by cooperation between the physician and surgeon from the start, with prompt interference in those cases which to the practiced eye show signs of making trouble, has reduced the actual recorded mortality of the disease to between two and five per cent. Even of those cases which come to operation now, the death-rate has been reduced as low as five per cent, in series of from 400 to 600 successive operations. When we contrast this with the first results of operation, when the cases as a rule were seen too late for the best time of interference, and from twenty per cent to thirty per cent died; and with the intermediate stage, when surgeons as a rule were inclined to advise operation at the earliest possible moment that the disease could be recognized, and from ten per cent to fifteen per cent died, we can see how steady the improvement has been, and how encouraging the outlook is for the future.
Cases which have weathered one attack of appendicitis are of course by no means free from the risk of another. Indeed, at one time it was believed that a recurrence was almost certain to occur. Later investigations, based upon larger numbers of cases, now running up into the thousands, give the rea.s.suring result that though this danger is a real one, it is not so great as it was at one time supposed, as the average number in whom a second attack occurs appears to be about twenty per cent. This, however, is a large enough risk to be worthy of serious consideration; and in view of the fact that the mortality of operations done between attacks is less than one per cent, it is generally the feeling of the profession that, where there is any appreciable soreness, or tenderness, or liability to attacks of pain in the right iliac region, in an individual who has had one attack of appendicitis, the really conservative and prudent procedure is to have the source of the trouble removed once and for all.
The four princ.i.p.al symptoms of appendicitis are: pain, which is usually felt most keenly somewhere between the umbilicus and the right groin, though this is by no means invariable; tenderness in that same region upon pressure; rigidity of the muscles of the abdominal wall on the right side; and temperature, or fever.
No matter how much and how variegated pain you may have in the abdomen, or how high your temperature may run, if you are not distinctly sore on firm pressure down in this right lower or southwest quadrant of the abdomen,--but be careful not to press too hard, it isn't safe,--you may feel fairly sure that you haven't got appendicitis. If you are, you may still not have it, but you'd better send for the doctor, to be sure.