CHAPTER IV






    Pathology: Formerly very little was written about the pathology of the appendix, the writers describing more the lesions of the cecum and surrounding structures. After the birth of the surgical craze, the exciting cause was located, or supposed to be located in the appendix, and the abnormal condition of the cecum was and is considered to be secondary or due to the lesions found in the appendix. The profession must evolve beyond its present tendency to look for cause in the organ. First understand the general then the special will be apparent.

    The pathology of the appendix has now grown exceedingly voluminous, and if it were as valuable in quality as it is great in quantity the necessity for more investigation would be removed.

    Appendicitis means inflammation of the appendix. This inflammation may affect the whole structure or merely a part. Catarrhal appendicitis affects only the mucous membrane.

    The appendix may be gangrened, wholly or in part. At times only the mucous membrane is gangrenous. The mucous membrane may be ulcerated and the pus penned in because of a closure of the mouth from swelling.

    Concretions are found in the organ at times. These are evidently formed inside the appendix, for they arc often too large to enter in the form in which they are found.

    When there is perforation of the appendix the result is peritonitis according to some authors, and, according to others just as great, this is disputed I belong to the latter class in belief.

    The pathology of appendicitis is necessarily touched upon more or less in going over the etiology, symptoms, and treatment of the disease, and variation is the rule, for how could it be otherwise when subject and environment must always vary ?

    As soon as an inflammation starts, the first thing that nature does is in the line of enforcing the first law of cure, namely: rest. To bring this about the musculature is set, rigidly contracted, thus fixing the parts. The contraction, of course, will be in keeping with the irritation of the parts; great pain means great rigidity, and vice versa. This being true, the harm that must come from keeping the stomach and bowels irritated by giving drugs and food should be plain to any mind capable of reasoning and willing to think.

    The more food given the more gas, pain and rigidity, and the more rigidity the more complete the obstruction, and the more complete the obstruction the more retention of gas. I need not enumerate the evils due to gas distention, for they should be apparent.

    If the obstruction caused by the swelling incidental to the hyperemia and inflammation is not already complete, the fixing or muscular rigidity completes it. After the obstruction is complete, if there is diarrhea, which is frequently one of the first symptoms, it comes from below the cut-off.

    The inflammation of the cecum and appendix is similar to inflammations elsewhere; the capillary blood vessels become engorged, the circulation becomes sluggish, and this causes swelling; the tissues then grow dark from the congestion. This condition is similar to tumefaction in general. which is favorable to abscess formation.

    When the local irritation and inflammation start with enough impetus to evolve an abscess the parts become fixed, as stated above, and the environing structures assume an attitude of alligated defense. There is a drawing together of neighboring tissue; the momentum, which should be recognized as the brood mother and care-taker of everything vital in the abdominal cavity, joins with contiguous structures and all become welded together by a friendly adhesive inflammation. When this defense is complete the abscess is walled in so completely and with such thoroughness that all possibility of intraperitoneal rupture rests with the blundering, heavy-handed, trouble-hunting profession; and if nature ever fails to complete the building of this wall of defense it will be because she has been interfered with by officious meddling in the name of scientific healing.

    There is no question but that many of these patients are seriously handicapped and others positively killed by unskillful, overzealous, superfluous examinations. A heavy-handed attendant should never be allowed to manipulate swellings in the right iliac fossa, nor in any other suspected region, for fear of destroying nature's defenses, and possibly rupturing an abscess, the contents of which will be emptied into the peritoneal cavity, causing peritonitis and death.

    Seeds are seldom found in the appendix and the fear of swallowing them because they may lodge in it is not well founded. There is no question but that this organ has the power, when normal, of taking care of itself. It has a peristaltic action and can expel anything that is capable of gaining entrance.