—Every attack of appendicitis, no matter how mild, predisposes to a repetition of the trouble, in mild or in fulminating form. Every appendix once inflamed has had its blood supply compromised and may break down easily upon a second attack. While not every patient who has once suffered in this way should necessarily suffer again, the majority who have had one attack may have another. No one can be prophetic in this regard and no one may truly assert that several mild attacks may not be followed by another most severe. That an appendix has been once inflamed is sufficient to justify its subsequent removal. That it has been several times involved makes operation next to imperative. Even repeated attacks of appendicular colic predispose to trouble in this region. In any appendix which has in this way frequently excited suspicion, or which gives rise to frequently recurring though mild colicky pain and local tenderness, especially when coupled with mild stercoremia, indications are for removal. It may be safely laid down, then, as a rule, to which there should be few exceptions, that any appendix which causes frequently recurring or almost continuous trouble should be removed.
Causes.
—It is impossible in any brief summary to include all the possible causes of appendicitis. Those mentioned below are perhaps those most commonly recognized or pronounced, yet the list is far from complete. First of all it should be remembered that the disease occurs in a vestigial organ, containing relatively considerable lymphoid tissue, especially around its neck, that it is comparatively poorly supplied with blood, and that such tissue under such circumstances inflames easily and breaks down quickly. Doubtless the trouble in some instances commences within the tiny intestinal tube. At other times its originating cause lies without, as, for instance, when its blood supply is interfered with by pressure of an overloaded cecum, by tumors, or by violent intestinal activity; this especially in connection with an appendix firmly anchored and not freely movable, it being so fixed in many instances that it cannot readjust itself easily to varying conditions. Thus an overloaded cecum may first press upon the appendix and then by violence of activity so displace it that it may easily succumb. Again in those appendices which hang downward into the pelvis there is little or no drainage by gravity, and they may easily become overloaded. A movable kidney may also disturb the integrity of an appendix in certain locations. Foreign bodies frequently excite pernicious activity, especially fecal concretions, and actual calculi or miniature enteroliths. Traumatism sustains a certain relation to some cases of violent activity of the psoas muscles in athletes, which may upset the circulation of appendices which lie directly upon the muscles involved.
Many of the causes mentioned above are predisposing rather than actual. The actual exciting causes of acute infection have mainly to do with germ activity and with vascular supply. It is well known that the more virulent the organisms the more acute the resulting inflammation, and it is also well known that colon bacilli and the ordinary pyogenic organisms vary in virulence within wide limits, and that mixed are often more acute than simple infections. Typhoid bacilli, tuberculous bacilli and the like vary in the same way, and, in company with other germs, may easily light up serious disturbance.
Complications.
—Of the complications which may accompany or ensue upon appendicitis the most common are those which involve the peritoneum, either local or general. Acute peritonitis is to be feared not only because of its autotoxic expressions, but because of the acute obstruction which it may produce by gluing intestinal loops together and paralyzing their motility. When to more or less widespread peritonitis are added general sepsis, with all its possible complications, and such further local expressions as cellulitis, which may be pericolic, subphrenic, perineal, or pelvic, or phlebitis which, involving the portal system, would soon lead to formation of hepatic abscess, it will be seen how easily the case may become serious. Furthermore not only may the ovary and tube suffer, but cystitis and nephritis may occur as toxic complications, while finally, by violence of the ulcerative process, a fecal fistula may form. This is by no means a complete list, but includes some of the more frequent complications.
Symptoms of Acute Appendicitis.
—Pain with nausea, tenderness, and rigidity constitute the triad of the most indicative early signs and symptoms, each of which needs to be considered by itself.
Pain.
—Pain is at the same time an important yet variable feature. In few other acute lesions does it vary as much in degree and location. Generally it is referred at first to the more central portion of the abdomen, as around the navel or between it and the right side of the pelvis. Later it may be localized at some widely distant point, as, for instance, far over upon the left side. Such vagaries may be held to be due to peculiarities of emplacement of the appendix, and would indicate that the organ will probably not be found in its most common location, but rather extending to the left or hanging over into the pelvis. When the appendix is attached to or lies near the bladder there may be considerable pain in the pelvis and in the bladder. It should be remembered that the parietal peritoneum is much more sensitive than the visceral, and in proportion as the lesion approaches the surface more exact information may be gathered from location of pain. Occasionally it may be referred to the region of the gall-bladder, or even to the chest above the diaphragm. In some instances it is agonizing, almost from the outset; in others it is never very severe. The rapidity of the process may be measured to some extent by the intensity and character of the pain. When the disease resolves slowly and kindly pain gradually subsides, but the sudden subsidence of pain, especially without equal improvement in other respects, is a bad rather than a good sign, indicating probably that perforation has occurred.