Appendicitis and the antibiotics

Autor: Paul W. Harrison
Rok vydání: 1953
Předmět:
Zdroj: The American Journal of Surgery. 85:160-163
ISSN: 0002-9610
DOI: 10.1016/0002-9610(53)90476-0
Popis: PPENDICITIS is a disease of civilization A like automobile injuries. Primitive peopIes past and present have been immune. In contrast civiIization apparentIy aIways brings this disease with it. It did so thousands of years ago in Egypt’ and it does so now. Fifteen years ago the writer watched appendicitis make its appearance in the coast communities of Arabia. Western civiIization was coming in. PreviousIy no appendicitis had been seen there, but in a few years a very considerabIe incidence developed. It seems unbeIievabIe but no suggestion emerged as to the cause. We came to no concIusion at a11 as to what eIement in civiIization produces this resuIt. The pathoIogist has described the microscopic anatomy of appendicitis in very compIete detai1, but he has not heIped us much in the matter of etioIogy. This is one of the diseases in which through an apparentIy unbroken epitheIia1 surface, pyogenic bacteria gain entrance to the body ceIIs. This is foIIowed by necrosis and abscess formation. BoiIs are a disease of the same kind. Appendicitis is a more serious disease than boiIs, because with rare exceptions the natura1 reactions of the body Iimit the boi1 to a singIe smaI1 area of necrosis and pus formation. These protective reactions are active in the appendix too, but here in a very considerabIe number of cases (20 per cent in our series) before the waIIing off of the abscess is compIete, the thin waII of the appendix has been perforated and from the intestina1 interior a new and dangerous group of pathogens enter the peritonea1 cavity itseIf. We do not see this type of bacteria1 invasion eIsewhere in the intestina1 tract, and we do not see it in animaIs. It seems remarkabIe that previous to 1886 in spite of much cIinica1 study and many post-mortems, we did not even reaIize that it is an affair of the appendix. Fitz of Boston studied 257 such autopsies2 and came up with an insight which is one of the miIestones of modern medicine. He did not penetrate into its essentia1 etiology, and so he contributed nothing to its prevention. However, he Iocated it accurately and outIined its symptom pattern. The remarkabIe progress in the treatment of appendicitis during the past sixty-Iive years is the resuIt of his work. So far that treatment has been pureIy surgica1. We have Iearned to detect the earIy stages of inflammation in this organ. Then we promptly remove it with a mimimum of damage to other structures. The mortaIity of such operations is very Iow, far under I per cent. When treatment is delayed and the peritoneum is contaminated, the results of operation are not nearIy as good. However, since the introduction of the antibiotics the resuIts in these operations too have improved. Some cIinics have reported series of 1,000 or even 1,600 appendectomies without a death. With the realization that peniciIIin can inactivate the pyogenic bacteria, it was inevitable that the treatment of appendicitis should come up for review. We do not amputate a finger when a boi1 is discovered on it. We inactivate the staphyIococci by means of peniciIIin and the finger heaIs by itself. The pyogenic bacteria which penetrate the mucous membrane of the appendix, streptococci most IikeIy, are more susceptible to the action of peniciIIin than are the staphyIococci of the boi1. If the appendix were easiIy accessibIe Iike the finger, we would Iong since have been treating its infections with penicifhn. Against the infection which foIIows contamination of the peritonea1 cavity, we are not so we11 armed. The situation is more comphcated for we are no Ionger deaIing with a singIe causative organism. A great number of different bacteria gain entrance to the peritoneum, when the appendix waI1 is perforated, and we do not know which are responsibIe for the peritonitis that resuIts. In such cases in addition to the toxins of the infecting organisms the patient suffers very
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