Synonyms

Scolecoiditis; Perityphlitis; Paratyphlitis; Appendicular inflammation.

Definition

Inflammation of the appendix, characterized by localized pains, commonly fever and digestive disturbances.

General Remarks

The inflammatory lesions involving the right iliac region were formerly designated as typhlitis (inflammation of the caecum itself), perityphlitis (inflammation of the peritoneal covering of the caecum), and paratyphlitis (inflammation of the retro-peritoneal connective tissue of the caecum). Grisolle 1 was the first to maintain that inflammation of the caecum could hardly give rise to such grave lesions as are found in the right iliac fossa, for even ulcerations of the caecum and colon do not, as a rule, show any tendency to extend into the neighboring connective tissue. He ascribed the above conditions to an inflammation of the appendix, which organ shows a tendency to perforate and to lead to abscesses in the right iliac fossa as verified by post-mortem examinations. The possibility of a stercoral typhlitis (inflammation of the caecum as the result of accumulated fecal matter) which was formerly generally accepted, is now held by but very few writers, as for instance, Lennander.1 Sahli,2 Nothnagel,3 Fowler,4 Sonnenburg,5 and others deny its existence.

The teachings of Grisolle found further support through the brilliant investigations of Reginald Fitz6 of Boston, Sands,7 McBurney,8 Weir,9 Bull,10 and Fowler of New York, were supplemented by the observations of Sonnen-burg, Sahli, Rotter,11 Roux,12 Talamon,13 and others, and are now generally accepted.

1 Grisolle: "Tumeura Phlegmoneuses des Fosses Iliaques. " Archives de Medecine, 1839.

Etiology

In former years much importance was attributed to the occurrence of foreign bodies like cherry stones, grape seeds, lemon and orange pits, date kernels, fish bones, pins, etc., within the appendix as causative factors of the inflammatory suppurative process. According to Fowler, the belief that the disease is frequently due to the engaging of foreign bodies in the cavity of the organ is based to a large extent upon purely speculative or imaginary conditions or erroneous observations. In a very large number of cases of this disease upon which he operated Fowler found but in two instances any body other than soft fecal masses which could be considered as being in any sense foreign. The fecal concretions within the appendix are now looked upon as of no importance whatever with regard to the causation of the disease, as they are also accidentally encountered in perfectly normal appendices. The opinion generally prevails that the inflammation is caused by micro-organisms which are conveyed to the interior of the organ in the fecal matter.

According to Nothnagel, however, fecal concretions play a prominent part in lesions leading to perforation of the appendix.

1 Lennander: " Ueber Appendicitis, " Wien, 1895.

2 Sahli: "Ueber das Wesen und die Behandlung der Perityphiiti-den." Correspondenzbl. f. Schweizer Aerzte, Basel, 1892.

3 Nothnagel: " Krankheiten des Darms, " Wien, 1898.

4 George R. Fowler: "A Treatise on Appendicitis," Philadelphia, 1894.

5 Sonnenburg: "Pathologie und Therapie der Perityphlitis, " Leipzig, 1895.

6 Reginald Fitz: American Journal of the Medical Sciences, 1886; and New York Medical Journal, 1888.

7 Sands: New York Medical Journal. 1888, p. 197-205, 607.

8 Charles McBurney: Annals of Surgery, 1891; Medical Record, 1892.

9 Robert F. Weir: Medical Record and Medical News, 1887-1892.

10 W. T. Bull: Medical Record, 1894.

11 Rotter: "Ueber Perityphlitis, " Berlin, 1897.

12 Roux: Revue de Medecine de la Suisse romande, 1890, 1891, 1892.

13 Talamon: "Appendicite et Perityphlite, " Paris, 1892.

Movable kidney has been assumed to be a predisposing factor in the development of appendicitis by Carl Beck1 and Edebohls.2 The much greater frequency of movable kidney in the female and the comparative infrequency of appendicitis in the latter as compared with the male sex seems to speak somewhat against this view.

Actinomycosis, tuberculous and typhoid ulcers are predisposing causes of the disease. Occlusion of the lumen of the appendix, either partial or complete, is likewise a predisposing factor. These occlusions may be the result of former inflammatory lesions, but are most frequently due to the retrograde changes which this organ is gradually undergoing in the process of evolution. According to Rib-bert3 and Zuckerkandl,4 the appendix is found obliterated in about twenty-five per cent of all living persons. Both these writers ascribe this condition not to inflammatory diseases, but to the progress of evolution which takes place in the appendix. This view is supported by the fact that obliteration of the appendix is found with gradually increasing frequency in more advanced age. Thus Ribbert found obliteration of the appendix in fifty per cent of persons above sixty years of age.

1 Carl Beck: "Appendicitis." Volkmann's Sammlung klinischer Vortrage, No. 221, Leipzig, 1898.

2 George M. Edebohls: Medical Record. 1898.

3 Ribbert: "Beitrilge zur normalen und pathologischen Anatomic des Wurmfortsatzes." Virch. Arch., Bd. 132.

4 E. Zuckerkandl: " Ueber die Obliteration des Wurmfortsatzes beim Menschen," Wiesbaden, 1894.

Why the appendix should be the seat of disease so very much more frequently than other parts of the intestine is a question which cannot be so easily answered. The fact that the appendix is a rudimentary organ in which processes of evolution are even normally discoverable makes it probable that it is imbued with less resistance against disease-producing agents. The comparatively narrow lumen of the appendix and Gerlach's valve make the emptying of this little canal a difficult matter. This, in connection with the scantiness of circular muscular fibres in the walls of the appendix explains the slowness with which substances within the appendicular cavity are emptied into the intestine. Stagnation of contents in this organ is certainly a predisposing factor for disease. The abundance of adenoid tissue in the appendix has been believed by some writers to be a predisposing cause of disease. Bacterial infections here take place in a similar manner as in the tonsils, and Sahli speaks by way of comparison of an angina of the appendix. Fowler and Van Cott 1 believe that the vascular arrangement of the appendix (scantiness of blood supply, the main vessels being almost end arteries) is responsible to a great extent for the frequency of disease in this organ.

Some of the blood-vessels and nerves are primarily affected, and the nutrition of the appendix being thus disturbed, diseases of an infective character easily take place. Another predisposing cause of appendicitis is displacement and malformation of the appendix.

While all the above-mentioned factors may predispose the appendix to disease, the real cause of the latter must be looked for in a bacterial invasion. Talamon was the first to lay stress upon the importance of microbes in ap-pendicitis. Nowadays all writers coincide with this view. Thus Tavel,1 Hodenpyl,2 Fowler, Wilson,3 Barbacci,4 and others ascribe a very important part to the bacillus coli communis (Escherich), which is almost always encountered in lesions of the appendix, either in the exudate, pus, or the walls of the appendix itself. Other micro-organisms are, however, frequently found either in connection with the bacterium coli commune or alone. Thus streptococcus pyogenes, pneumococcus, staphylococcus pyogenes aureus, bacterium lactis, bacillus pyocyaneus and pyogenes foetidus, proteus vulgaris, and others have been encountered. In most cases probably a mixed infection (several varieties of micro-organisms) takes place. The bacterium coli commune, however, is most frequently found, as it has a greater resisting-power and in the course of its growth usually causes disappearance of the other micro-organisms.

1 Van Cott-Fowler: "Treatise on Appendicitis."

Sex and age seem to play an important part in regard to the distribution of the disease. The male sex is much more frequently affected than the female. Thus,

Sonnenburg reports

130

cases

-

77

males,

53

females.

Rotter

"

68

"

-

44

"

24

"

Nothnagel

"

130

"

-

105

"

25

"

Bamberger5

,,

73

"

-

54

"

19

,,

1 Tavel und Lanz: " Ueber die Aetiologie der Peritonitis. " Mitthei-lungen aus Kliniken und Instituten der Schweiz, Basel, 1893.

2 Hodenpyl: " On the Etiology of Appendicitis. " New York Medical Journal, 1893.

3 E. Wilson: Cited after Fowler. 4 Barbacci: Lo sperimentale, 1893, fasc. 4.

5 Bamberger: "Die Entzi'indungen der rechten Fossa iliaca." Wiener med. Wocbenschr., 1853.

Volz1

reports

59

cases

-

45

males.

14

females.

Matterstock2

"

1,030

"

-

733

"

297

"

This preponderance of the male sex is already found in early life. Thus Matterstock observed 72 cases of appendicitis in early life (seven months to fifteen years), and among this number were 51 male children and 21 girls. The greater frequency of appendicitis in the male sex is explained by Van Cott as due to the circumstance that the appendix of the male has a less abundant blood supply than that of the female; for in the latter there is a collateral circulation derived from the sexual apparatus.

With regard to age all writers agree that appendicitis is most frequently encountered between the tenth and thirtieth years. It occurs less frequently in the first decade of life and in the thirtieth to fortieth years, and is quite rare in advanced age. The following table is submitted with a view of showing the frequency of appendicitis in the different decades of life as recorded by several eminent writers:

Ages.

Fitz.

Matterstock.

Nothnagel.

Total number..................

228

474

129

1 to 10.....................

22

46

1

10 to 20.....................

86

143

44

20 to 30.....................

65

158

57

30 to 40.....................

34

72

14

40 to 50.....................

8

30

7

50 to 60.....................

11

18

4

60 to 70.....................

1

5

2

70 to 80.....................

1

2

0

The frequency of appendicitis in relation to other diseases can be studied from the report of the autopsies made in the pathological institute of the Wiener Allgemeine Krankenhaus between 1870 and 1896. According to Noth-nagel, the total number of autopsies was 44,940. Among these the number of cases dying from appendicitis amounted to 148. The percentage of appendicitis, therefore, was 0.32. With regard to sex there were 107 males (72.3 per cent) and 41 females (27.7 per cent). The actual frequency of appendicitis among the living, however, is much greater than appears from these numbers, which relate only to cases which have resulted fatally.

1 Ad. Volz: "Die durch Kothsteine bedingte Perforation des Wurni-fortsatzes, etc.," Karlsruhe. 1846.

2 Matterstock: "Perityphlitis." Gerhardt's Handbuch der Kinder-krank.. Tubingen. 1880.

Morbid Anatomy

The pathological anatomy of appendicitis has been thoroughly studied recently, not only in autopsies but principally in operative cases. In the latter an insight is permitted into the changes which take place early in the disease. Fowler distinguishes four stages of anatomical lesions according to the spread of the morbid process involving the different tissues of the appendix. In the first stage (endo-appendicitis) more or less iutense inflammation of the mucous and submucous layers takes place. The second stage (parietal appendicitis) consists in an inflammatory process involving the interstitial or intermuscular structure of the body of the appendix. The third stage (peri-appendicitis) means an inflammatory process involving all the layers of the appendix, the peritoneum included. The fourth stage (para-appendicitis) consists in lesions involving the appendix and the neighboring tissues. This process is most often accompanied with suppurative inflammations of the connective tissue adjacent to that portion of the appendix which is not covered with peritoneum.

According to Fowler, the above described stages are not essentially different processes but further developments of one and the same lesion.

Riedel,1 Nothnagel, and others distinguish two different types of appendicitis which are of great clinical importance. They are the following: