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Title: Appendicitis: The Etiology, Hygenic and Dietetic Treatment
Author: John H. Tilden, M.D.
Release Date: August, 2003 [Etext #4314]
[Yes, we are more than one year ahead of schedule]
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The Project Gutenberg Etext of Appendicitis: The Etiology, Hygenic and Dietetic Treatment
by John H. Tilden, M.D.
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APPENDICITIS
THE ETIOLOGY, HYGIENIC AND DIETETIC TREATMENT
BY JOHN H. TILDEN, M.D.
Author of
"Impaired Health," 2 Vol.; "Cholera Infantum," "Typhoid Fever,"
"Diseases of Women and Easy Childbirth," "Venereal Diseases,"
"Appendicitis," "Care of Children," "Food," 2 Vol.; "Pocket
Dietitian."
=====================NOTICE*===================
You have recently purchased some of my earlier writings, hence the
following suggestion:
As my regular readers know, I do not favor the use of _protein_ and
starchy foods in the same meal. The only exceptions that I ever made
to this combination was the use of potatoes with meat in the same
meal and the serving of milk with starch. I still allow the
occasional use of potatoes with meat for well people, for the potash
content of the potato helps with the digestion of these two foods.
_But the combination of milk with starch I discontinued some years
ago._
In some of my former writings this correction has not yet been made,
therefore we are asking our readers to keep this in mind when
studying those particular works. Where you find milk in combination
with starch, change the milk to teakettle tea, which means hot water
with a little cream (which is fat, not protein) and a small amount
of sugar.
In some of my former writings this correction has not yet been made,
therefore we are asking our readers to keep this in mind when
studying those particular works. Where you find milk in combination
with starch, change the milk to teakettle tea, which means hot water
with a little cream (which is fat, not protein) and a small amount
of sugar.
*(This notice was slipped inside the book, printed on a small,
glossy sheet. Editor)
THE ROAD OF ILL HEALTH
To understand the cause of appendicitis we must go back to the
beginning, and when we do we find that it starts just where all
diseases start, namely, _where health leaves off! _When the laws of
health are broken for the first time, it can be said that the
individual has started on the road of ill health. How fast he will
travel and just what will be the character of the disease he meets
with will depend upon his constitution, inheritance, environment and
education.
APPENDICITIS
CHAPTER I.
This cut represents the back view of the cecum, the appendix, a part
of the ascending colon, and the lower part of the ileum, with the
arterial supply to these parts.
"A, ileo-colic artery; B and F, posterior cecal artery; C,
appendicular artery; E, appendicular artery for free end; H, artery
for basal end of appendix; 1, ascending or right colon; 2, external
sacculus of the cecum; 3, appendix; 6, ileum; D, arteries on the
dorsal surface of the ileum."--Byron Robinson.
The reader will see how very much like a blind pouch the cecum is,
2. The ileum, 6, opens into the cecum, all of the bowel below the
opening being cecum, the opening of the appendix, 3, is in the lower
part of the cecum.
The arterial supply to these parts is great enough to get them into
trouble in those people who are imprudent eaters, and it is also
great enough to save the parts when diseased if the patient has the
proper treatment.
For the benefit of the lay reader I will say that the blood-vessels
represented in the cut are the arteries; there are also veins,
nerves, and lymphatics imbedded in the folds of the peritoneum,
accompanying and paralleling the arteries, but they are not shown in
the cut.
The peritoneum is the lining membrane of the peritoneal cavity. It
is well to remember that there is nothing in the peritoneal cavity
except a little serum. The layman will say that the bowels are in
this cavity, but they are not; they project into the cavity, and
their outside covering is the lining membrane of the peritoneal
cavity, but they are truly on the outside of the cavity, and to
enable the layman to understand the anatomy so that he can apply it
when reading of the disease, I shall describe the course of an
ulcer: If an ulcer starts in the bowel it first eats through the
mucous coat which is the lining membrane of the bowel then through
the submucous coat, which is the second layer or coat of the bowel,
then through the muscular coat, which is the third layer of the
bowel; this brings the ulcer to the serous coat or peritoneum. When
the peritoneum is eaten through it is called perforation, for it
means that there is an opening into the peritoneal cavity, and,
unless the cavity is cut into, cleaned and properly drained death
will take place in a very short time. I say death is inevitable
without surgical treatment. In this I appear to be more radical than
the most radical, for the best authors have much to say about
perforation, diffuse peritonitis, and of patients who live after
perforation, as though it were a common occurrence; I say they are
mistaken.
CHAPTER II
_History: _Appendicitis did not become popularly known until about
twenty years ago--not till it was christened and baptized in the
blood of the surgical art. Of course the appendix has always been
subject to inflammation, just as it is now, but in former years the
disease we call appendicitis bore various names, depending upon the
diagnostic skill of the attending physician. Typhlitis and
perityphlitis were the names used to designate the disease now
covered by the word appendicitis.
The diseases that appendicitis may be confounded with and must be
differentiated from are obstruction, renal colic, hepatic colic,
gastritis, enteritis, salpingitis, peritonitis due to gastric or
intestinal ulcer, enterolith, obstipation, invagination or
intussusception, hernia, external or internal, volvulus, stricture
and typhoid fever.
The old text-book description of typhlitis and perityphlitis is so
similar to the description of the present day appendicitis that it
is not necessary to reproduce it. The symptoms given show
conclusively that they are really one and the same.
In the surgical treatment of appendicitis the American profession
has taken the lead, and the mention of this disease brings to mind
such names as McBurney, whose name is given to an anatomical
point--McBurney's Point--midway between the right anterior superior
spine of the ileum and the umbilicus, Deaver of Philadelphia, and
Ochsner and Murphy of Chicago. Those who are interested in the
surgical treatment of the disease can look into the methods of these
men, and many others. The medical literature of the day abounds in
exhaustive treatises on the subject of appendicitis and its surgical
treatment.
We are living in an age that will not be properly recorded unless it
be entered as _The Age of Fads._
Following immediately on the announcement of Lord Lister's
antiseptic surgical dressing which rendered the invasion of the
peritoneal cavity comparatively safe, came the laparotomy or
celiotomy mania. When it was discovered that opening the abdomen was
really a minor operation, it was soon legitimatized by professional
opinion, and rapidly became standardized as a necessary procedure in
all questionable cases--in all obscure cases of abdominal
disease--where the diagnosis was in doubt. The result of
popularizing and legitimatizing the exploratory incision, was to
cause those who failed to resort to it, in doubtful eases, to be in
contempt of the court of higher medical opinion, and to license
those of a reckless, selfish, savage nature to play with human life
in a manner and with a freedom that would make a barbarian envious.
The wave of abdominal operations that swept the country in the last
quarter of the nineteenth century was appalling. The slightest pain
during menstruation, or in the lower abdomen, in fact every pain
that a woman had from head to toes was put under arrest and forced
to bear false witness against the ovaries. It was a very easy matter
to trump up testimony, when real evidence was embarrassing, to
foregone conclusions; hence pains in obscure and foreign parts took
on great importance when analyzed by minds drilled in the science of
nervous reflexes, sympathies and metastases.
Normal ovariotomy (removing normal ovaries for a supposed reflex
disease) swept the whole country during the eighties and threatened
the unsexing of the entire female population. The ovaries had the
reputation of causing all the trouble that the flesh of woman was
heir to. Oophorectomy was the entering wedge, since then everything
contained in the abdomen has become liable to extirpation on the
slightest suspicion.
Those surgeons of greater dexterity or savagery, I can't tell which,
prided themselves in operating on the more difficult cases. Taking
the ovaries out was a very tame affair compared to removing the
uterus, tubes and ovaries; hence the surgical adept embraced every
opportunity for an excuse to remove everything that is femininely
distinctive.
About 1890 appendicitis began to attract the attention of those
surgically ambitious. The ovariotomy or celiotomy expert began to
feel the sting of envy and jealousy aroused by those who were making
history in the new surgical fad--appendectomy--and they got busy,
and, as disease is not exempt from the economic law of "supply
always equals demand," the disease accommodatingly sprang up
everywhere; it was no time before a surgeon who had not a hundred
appendectomies to his credit was not respected by the rank and file,
and an aspirant for entrance to the circle of the upper four hundred
could not be initiated with a record of fewer than one thousand
operations.
Thanks to the law of supply and demand the ovaries retired and gave
women a much needed rest. If they had continued to misbehave as they
had been doing before the appendix got on the rampage, the demand
for surgical work would have exceeded the supply of surgeons.
Diseases of all kinds are very accommodating; as soon as a
successful rival is well introduced they retire without the least
show of jealousy, showing that they are not strangers to the highest
ethics, their associations to the contrary notwithstanding.
There are many well written articles on appendicitis, but I believe
the monograph by A. J. Ochsner, M. D., is decidedly the best, and
when I refer to the best professional ideas on etiology, pathology,
symptomatology and treatment I have in mind the opinions set down by
Ochsner, for he has taken more advanced grounds in the medical
treatment of this disease than any other physician I know anything
about in this or any other country. If his "A Handbook on
Appendicitis" brought out in 1902, had come out three years before,
I should give him credit for being the first man on record to
proscribe the taking of food in appendicitis, but as my first
written advice on the subject was in the July, 1900, number of A
Stuffed Club,* two years before his book, I shall give myself the
credit for being the first physician to announce to the world _the
only correct plan of treating the disease and suggesting the
probable cause _which the intervening time has proven to be correct
The only reason I have for making this announcement is that in all
probability no one else will ever do so, and, as it is just and
right that I should have the credit, I do myself the honor. The
general rule is that if a new method of treatment comes out, or a
discovery of importance is made other than in the regular
professional channels, it will either be ignored or adopted (cribbed
is more expressive) and no credit given. This is a small matter, and
of no special consequence, yet it carries a meaning.
*(Editor's note: "A Stuffed Club" was the newsletter or journal
published by Dr. Tilden for many years.)
Previous to 1890 the most popular treatment was probably the giving
of opium; although this was far from ideal, "it had the advantage of
taking away the patient's appetite, relieving pain, and putting the
bowels to rest."--Ochsner. If there were any way to prove it, we
should find that next to surgery opium is still the most popular way
of treating the disease.
To-day there is no other disease which brings surgery so quickly to
mind as does appendicitis, especially if the victim can stand for a
good, large fee. It is only human I presume, for surgeons to defend
the operation. They believe in it, and are not willing to
investigate, for they are satisfied. They know or should know that
ninety per cent of all the surgery practiced to-day has no excuse
for its existence--no more right to be protected by the laws that
weld society together than has any other graft that exists by the
grace of public ignorance and credulity. This operation has for some
time been the largest single item of revenue for the profession.
Thirty-four years ago I was called in consultation to see my first
case of what was then generally recognized as perityphlitis or
typhlitis--inflammation of the connective tissue about the cecum. It
was a typical case of what is today called appendicitis. I advised
the doctor to cease his fruitless endeavors at securing relief by
giving drugs, and give the patient nothing but water. As I remember
now, it took about four weeks for this patient to recover. This
plan--positively nothing but water--has since been a part of my
treatment in all such diseases.
CHAPTER III
_Etiology: _To understand the cause of appendicitis we must go back
to the beginning, and when we do we find that it starts just where
all diseases start, namely, _where health leaves off! _When the laws
of health are broken for the first time, it can be said that the
individual has started on the road of ill health. How fast he will
travel and just what will be the character of the disease he meets
with will depend upon his constitution, inheritance, environment and
education. I do not mean by education, school or book education; I
mean intuition--that knowledge which evolves from home life and
habits. I mean, has he any self-discipline? Does he know anything
about self-denial? Has he any conception of a control higher than
impulse? Has he been brought up to know that there is a limit to the
gratifying of wants and desires beyond which, if he goes, he must
make good with laws that are as exacting as they are invariable?
Does he know that nature shows no favoritism? Does he know that
there are laws regulating his intercourse with men--with
everything--that exact absolute justice from him? And that, if he
takes advantage of weakness or ignorance because he can, or if he
secures an advantage through credulity or trickery, he must settle
for the crime before a judge who is absolutely just! If he has this
education, which is a constitutional ingrafting from the mother's
blood, fructified by a like potential father, he will be almost
immune from all diseases. This is an education that can not be
secured unless the individual has the prenatal and environing
influences to differentiate these static attributes of his nature,
and, if he has, the result will be that all these qualities will
come to him because "like attracts like." In an atmosphere where
others attract evil this individual attracts good. The same is true
on the physical plane. Those who have diseased bodies always have
disease making habits, hence they attract from a given environment
all the disease making impulses, while those of healthy bodies have
health imparting habits, and attract from the same environment the
health impulses for which they have an affinity.
The constitution, inheritance and education of all mankind will vary
from the highest to the lowest types. As we go down the scale from
those with ideal physical and mental health, we see man becoming
more and more the victim of disease.
It is no uncommon thing to find people of seeming intelligence who
appear surprised when told that they have brought upon themselves
such a vulnerable state of health from wrong eating and care of
their bodies that they are in line for appendicitis, pneumonia,
typhoid fever, bowel obstruction, or blood poisoning. In such types
blood poisoning would surely follow a complicated fracture of a
bone--a fracture where the ends of the bone cut through the flesh
causing an open wound.
Pregnant women belonging to this class go into confinement with
their blood so heavily charged with the by-products of an imperfect
metabolism that they are very liable to have septicemia.
People who think they must have "three square meals a day" must
have catarrh, rheumatism, tonsilitis, quinsy, pneumonia, typhoid
fever, and all sorts of bowel trouble including appendicitis. Why!
Because three meals a day consisting of bread, potatoes, eggs, meat,
fish, butter, milk, cheese, beans, etc., overwork the metabolic
function and as a consequence organic functioning is impaired, cell
proliferation falls below the ideal, bodily resistance falls lower
and lower, the intestinal secretions lose their immunizing power
more and more, until at last the body becomes the victim of every
adverse influence. At first fermentation--indigestion--shows
occasionally; the intervals between these attacks of acid stomach,
or fermentation, grow shorter and shorter until they are of daily
occurrence; accompanying this fermentation there is gas distention
of the bowels, and this inflation in time interferes with their
motility and weakens them so that sluggishness is succeeded by
obstinate constipation.
Every step of this evolution shows an increasing toxic state of the
fluids in the bowels. After constipation is established the efforts
at securing evacuations are of such a nature as to irritate the
cecum. Drugs to force movement cause painful distentions of this
portion of the bowels. The drugs stimulate peristalsis of the small
intestine; each wave from the small intestine breaks on the walls of
the cecum, for the colon is loaded with fecal accumulations so that
the onrushing contents of the small intestine can not be received by
the colon; hence the force of the whole peristaltic impact is spent
on the cecum, which must endanger the integrity of the mucosa as
well as the musculature.
This point of the bowels, the cecum is more endangered from diarrhea
than any other. The toxic ptomaines are especially liable to create
a local infection if nothing more.
This state of the intestines--toxic state--is a constant menace to
health; in fact the organism is heavily taxed to maintain its
defense.
The overcrowding of metabolism, as explained above, the chronic
constipation and toxic bowel secretions, I recognize as the chief
factors--the necessary and leading factors--in the building and
maintaining of that constitutional state which I am pleased to
denominate _Constitutional Catarrh. _When this state is established,
it can be said that the individual is ready to develop any phase of
disease that circumstance, accident, or caprice of fortune or
environment may offer.
The constant presence of gas in the bowels becomes more and more
menacing to the cecum as the constipation increases. The filled-up
condition of the bowels--the colon and rectum--prevents the easy
passage of gas from the bowels, hence it accumulates in the
ileo-cecal region and keeps the cecum distended.
The constant dilating of the cecum from gas accumulations and the
forced dilations from diarrheas made either from drugs or irritating
foods, must not only damage the cecum but the appendix as well; for
the appendix opens into this part of the intestine and it is
reasonable to believe that it suffers distention from gas and that
toxic secretions are driven into it. When its function is not
interfered with by an unusual pressure as from constipation, no
doubt it can empty itself and does do so.
When it is understood first of all that appendicitis--the
inflammation known as appendicitis--is a local manifestation of a
general or constitutional derangement, the cause for this local
manifestation may be taken up.
In order to understand why the disease localizes we must refer the
reader to the peculiar anatomical construction of the cecum and the
appendix, and their relation to other parts. The cecum is a large,
blind pouch, one of the shortest of the several divisions in the
continuity of the intestinal canal, which begins where the small
intestine ends, and ends where the large intestine begins. Its blind
end or pouch is down; this dependent position makes it peculiarly
liable to impaction and the injuries which are disposed to come from
distention; for, as the colon ascends from its connection with the
cecum, the force of gravity must be reckoned with.
The colon is very liable to be more or less distended with
accumulations, and especially is this true of those of sedentary
habits, for a call to evacuate the bowels is frequently postponed.
This postponing of duty to nature has evolved, in all these years of
civilized life, a weakened functioning so that man is more subject
to constipation than any other animal. The bowels are educated to
tolerate a great accumulation and the pretty general habit of taking
drugs to force action has grown a weakened state which is the
natural sequence of overstimulation and as this has been going on
generation after generation it has become more or less
transmissible.
The cecum, situated as it is, must bear the brunt of the evil
effects of constipation. When the large intestine is full or
distended, as it usually is in cases of chronic constipation, so
that nothing can pass out of the cecum this organ becomes a jetty
head, so to speak, against which the peristaltic waves from the
small intestine break. The full force of the peristaltic waves from
the small intestine with its onrush of fluid or semifluid contents
subjects the cecum to great distention and strain.
If there were any way to prove that so-called appendicitis is more
common to-day than in former times, it is reasonable to believe that
the irritating effect of the pretty general habit of taking
cathartic medicine has had more to do with bringing it about than
any other one thing.
Distention, with the straining of the walls from peristaltic
onrushes as described above, and the infection that this part of the
alimentary canal is subjected to because of the decomposition of
food that is going on to a greater or less extent in all victims of
constipation, are the causes of inflammation in the cecum. If the
inflammation involves the appendix or the cecal location of the
appendix, it may be called appendicitis, but the appendix is
involved the same as any other contiguous part. Any mind capable of
reasoning should have no trouble in rightly assigning the
responsibility of this disease, if sufficient attention be given to
anatomism.
There is not any very good reason for one capable of analyzing, to
jump at the conclusion that the appendix is the cause of the disease
because it is frequently found in the field of inflammation. The
same reasoning would make Peyer's glands the cause of typhoid fever.
The unwholesome condition of the intestinal tract which is the
immediate or exciting cause of appendicitis and other diseases
peculiar to this location, is brought on by improper life; not one
cause, nor a dozen special causes, but anything and everything that
break down the general health create this condition; then add the
accidental eating of decomposition, or add decomposition,
auto-generated, and we have the necessary data.
The opening of the appendix is so very small that inflammation of
the cecum soon closes it and then we have a mucous surface without
drainage, which means obstruction--opposition to the requirements of
nature--for one of the functions of the mucous membrane is to
secrete and this secretion must have an outlet or the part becomes
diseased.
According to the theory of bacteriology a micro-organism is to blame
for appendicitis. If this were true it would relieve humanity of all
responsibility. There is a disposition on the part of man to shirk
responsibility and the germ theory is not the first theory of
vicarious atonement that he has spun. Those who wish to shirk all
kinds of responsibility by adopting the germ theory and by making
micro-organisms the scape-goat may do so, but I would advise all
sensible people to keep in mind the following truth: _Violated
hygienic laws predispose to disease; _then, when resistance is
broken down, the immediate and exciting cause may be anything
capable of laying on the "last straw."
The micro-organisms are present wherever there is life and are as
necessary to life as they are to death.
Ochsner states that in nearly all instances the disease can be
traced to the common colon bacillus, which is always present when
the intestine is normal. The three pus cocci are sometimes blamed,
and so are the bacilli of typhoid fever, tuberculosis and the ray
fungus (so-called cause of lumpjaw).
Other causes given are: Edema and congestion closing the lumen of
the appendix, thus preventing drainage; constipation; digestive
disturbances; traumatism; eating too freely while in an exhausted
condition.
"Whatever the predisposing causes may be in any given case, the
exciting cause is always some infectious material. The colon
bacillus is always present in the lumen of the alimentary canal and,
although it is harmless under normal conditions, when these
conditions arc changed and there is an abrasion, an abnormal
condition of the circulation, or a lack of drainage, it becomes at
once actively pathogenic. With a perfectly normal peritoneum a
considerable quantity of a pure culture of colon bacilli may be
injected into the abdominal cavity without causing any harmful
effect, as has been shown by the experiments of Ziegler, but if
there is any disturbance in the circulation or nutrition of the
peritoneum, the same quantity taken from the same culture will give
rise to a dangerous peritonitis."--Ochsner. [This goes back to the
constitutional derangement. First of all low resistance, then any
exciting cause is sufficient.]
In studying the cause of organic disease, the first thing to
consider is the organ itself. A knowledge of its structure and
function will indicate what diseases it is liable to have--what the
character of the disease must be.
Reason would say that an organ can be deranged in two general ways,
namely: structurally and functionally. In a structural way it may be
impaired either by coming in violent contact with extraneous
objects, or it may be crowded or pressed upon by enlarged or
displaced associate organs. In a functional way the derangement may
be brought about from overwork or underwork. A digestive organ may
be overworked by being given too much food, or food of too
stimulating a quality; or the over-stimulation may come from poisons
coming into the food from without or developing in the food after
its ingestion. The bowels may be injured by coming in violent
contact with external objects. When this is the cause there will be
the history of accident, etc.
The functions of the bowels are to furnish a dissolving fluid which
is secreted by glands situated in their structure and opening into
their lumen; besides the secreting glands they are provided with
power to excrete and absorb. The organs for the accomplishment of
these purposes, like the secretory glands, are situated in the
structure and open into the canal. Besides the functions of
secretion, excretion and absorption, the bowels act as the great
sewer of the body.
The dissolving fluids, or digestive fluids, have the power to
overcome fermentation when the general health standard is normal;
when the tone of the general health is lowered these digestive
juices are lacking in power; hence they are not able to control
fermentation if food be ingested to the amount usually taken in
health. The power to oppose fermentation by the digestive juices
ranges all the way from nil to the resistance usual to a man of full
health and vigor.
It being the function of the bowels to digest food and overcome
fermentation, it stands to reason that to accomplish this function
they must be normal--they must have a proper supply of nerve force
and the supply of nutrition must be normal or they can not furnish
the proper amount and quality of secretions. To have all these needs
supplied they must be reciprocally related to every other organ
associated with them in the organic colonization which totals a
human being.
On account of the reciprocal relationship between the bowels and the
rest of the colony of organs, the bowels must share alike; that is,
in the matter of distribution of forces no organ of the body can be
favored; all must go up and all must come down together. They must
all share alike; hence the bowels have their share of the general
tone and, if they are required to do more than a reciprocal amount
of the work, it stands to reason that they can not do good work;
and, if they can not do good work, the whole colony must suffer in a
general way, while the bowels must also suffer in a special way. The
function of drainage or sewerage is very important, and the
perversion of it brings on much ill health. The principal perversion
to the function of sewerage is that of constipation, the location of
which is limited to the lower portion of the large intestine, a
section of the canal least endowed with digestive and absorptive
power.
The result of overwork is depression--exhaustion--prostration; and
what does that mean to an organ? Is it possible for an overworked
organ--a depressed organ--an exhausted organ--a prostrated organ--to
function normally? Is it reasonable to believe that an organ that is
inflamed can function properly? Such questions are absurd, I
acknowledge. Questions that carry foregone conclusions on the face
of them write the questioner down an ass, which I also acknowledge.
But I desire to rebut the inference these questions reflect on me by
making a few requests which show that there is a lot of professional
reasoning based on that sort of logic which justifies my childish,
senseless questions.
Show me a physician, or if you can not show me one, give me the name
of a physician who does not feed children in cholera infantum. I
want to know a few physicians who do not feed in typhoid fever. I
should like to make the acquaintance of a few physicians who do not
feed in appendicitis until the disease is made desperate, and who do
not begin to feed long before it is safe to feed.
In all diseases where there is fever, in all diseases where there is
pain, _nutrition is suspended--_metabolism is stationary. I wish
some one would be kind enough to inform me of an M. D. who does not
feed patients suffering with pain and fever.
If the inferences these requests carry are true, has the personnel
of the profession any right to treat my questions with contempt and
declare that they are childish!
No! Diseased organs can not function properly and it is absurd, yes
worse than that, it is criminal to feed under such circumstances.
The result of feeding is the prolongation of disease by building it
afresh with every spoonful of food.
I say that every relapse and every complication that have ever
occurred in any disease being treated by any physician from the top
to the bottom of the profession' even if the treatment was the very
best that could be furnished by the highest skill in any of the
drug-systems, if said treatment consisted of drugging and feeding,
were brought on by the treatment.
All diseases of the alimentary canal, not of a traumatic origin or
from the accidental or intentional swallowing of corroding chemicals
or from the continuous use of drugs on the advice of physicians,
come from infection or intoxication. Why not? This is the most
reasonable cause, for the fecal matter in health is toxic and it
only requires one step further to sufficiently intensify the
putrefactive change to create irritation of the mucous membrane. Of
course there is a degree of immunization taking place all the time.
Many people have themselves inured to the constant saturation of
fecal intoxication. It is true they are building a large toleration
for that particular poison, but their general vital tone is being
lowered continually and somewhere and in some way there is a
deposition taking place. In women there may be an old cicatrix in
the neck of the womb or a lump in the breast; the circulation has
been impaired for several years and now because of the
overstimulation that has been going on so long, there is a greatly
enfeebled circulation and deposits are taking place. The tumor in
the breast becomes cancerous; the scar in the womb takes on
malignancy; the arteries harden; the circulation in the spinal cord
becomes so impaired that induration is induced followed by ataxia;
and other troubles of a like character could be mentioned. These are
the most favorable results for, while these cases are winding their
weary, sluggish course to the land of rest, there have been many
taking the rapid transit.
I wish to emphasize the fact that one of the constant symptoms
peculiar to this class of inebriates is constipation. As a class
these people carry very large quantities of fecal matter in their
lower bowels. This constantly loaded condition of the lower bowels
is relieved occasionally by a sharp, irritative diarrhea,
accompanied by nausea and vomiting or not. The diarrhea is often
preceded by a few hours of acute pain that causes some talk of
appendicitis and operation but, much to the discomfiture of the
doctor, the bowels start up and relieve all suffering.
A few of these cases develop a chronic colitis. The bowel discharges
are more or less coated with catarrhal secretion. Not all are
constipated; obstinate diarrhea is the character of some; there are
here and there a few cases that throw off a membrane two or three
times a year, often in appearance like a cast of the lumen.
Enteritis, entero-colitis and dysentery are different forms of bowel
troubles that cause much uneasiness, for it is such a common matter
to call everything appendicitis, and if the patient is credulous and
gullible he may be operated upon even if his disease is a proctitis
or a case of gas in the bowels.
It is no uncommon thing for a case of obstinate constipation,
accompanied by colic, to be operated upon for removal of the
appendix if the pain is obstinate and hangs on long enough for the
patient to be scared into an operation. The pressure from
constipation and the constant strain on the cecum render this
particular section of the bowels liable to take on local
inflammations.
The recognized literature of the day attributes all infectious
disease to germs or micro-organisms. That all diseases originating
in the alimentary canal are due to infection there can be no doubt,
and all agree, but I do not agree with the prevailing opinion that
germs or micro-organisms are the primary cause of infection, for
that theory is not sufficient; it can not possibly cover the ground
and account for everything that takes a part in the great array of
causations that must be considered. To my mind it would be just as
reasonable to say that germs cause health, and I defy any
bacteriologist to prove that micro-organisms cause disease any more
than they cause health; and if he can't prove that germs are more
pathologic than they are physiologic, but does succeed in proving
that they are equally important to health and to disease, we can
agree to that equal importance and should be able to go on agreeing
and declare that if germs are the cause of disease they must also
cause health and it is our duty to spend at least a part of our
professional time in cultivating health germs. In fact it would be
much better to spend all our time in cultivating health germs and
insisting on people being inoculated with the serum from these germs
so that there will develop such a state of health that the disease
germs will have no show.
How can a sane man forgive himself for advocating inoculation by
disease germs to cause immunization when by the use of health germs
the health could be built so strong that the pathogenic germs would
have no show. If this theory won't work both ways it is a false
theory, and professional men, who should be logical if any set of
men are logical, should be ashamed to advocate any theory that is
based upon a half-truth.
As I stated the structure and function of an organ point to its
possible maladies. The cecum is the gate-way between the large and
small intestines. Its function of passing the contents of the small
intestine into the large is obstructed much of the time. It is
constantly subjected to bruising, pressure, stretching, and
obstruction, and is, therefore, more liable to be the seat of local
inflammations than any other part of the bowels. Diseases of this
part of the bowels are liable to come at any time of the year; but
in hot weather the tendency to fermentation is much greater than at
other times of the year, and bodily resistance is reduced because of
the enervating influence of the heat, of too long working hours, and
of too short nights for sleep, and of the ever-present, omnipotent
and omnivorous appetite which is taking into the stomach and bowels
food beyond the digestive capacity both in quantity and quality; all
these join in intensifying the habitual toxcicity of the bowel
contents to such a state of virulence that those parts of the bowels
already weakened, because of the mechanical injuries before referred
to, take on a local inflammation. Diarrhea may be the consequence
and the bowels may have a thorough cleaning out and the whole
trouble end in a few days. Or the constipation may be of a nature
that evacuations, such as the patient has been having, have been
passing through the center, leaving a coating on the lumen, but
hollowed out in the center. When the inflammation starts causing
increased bowel contractions--peristalsis--there is a breaking down
of the walls of this fecal ring resulting in complete obstruction.
The ineffectual bowel contractions then serve to irritate and
inflame the affected part still more. The local inflammation is at
first superficial but the increasing toxicity of the fluids that are
held on these parts causes the inflammation to take on ulceration.
The inflammation or ulceration may remain superficial, and be
located in the lower portion of the small intestine, then the
disease is enteritis. If the bowels are cleared out and the
patient's blood freed from intoxication, the attack ends; if not the
disease will be called enteritis or catarrh. If the infection is a
little greater and extends a little deeper causes inflammation of
Peyer's glands then the type of the disease will be typhoid fever.
Children troubled with constipation will sometimes be taken with
fever and pain in the right iliac fossa and, on examination, a
fullness will be found; the sensitiveness will not be so great but
that an examination can be made and a sausage shaped tumor may be
outlined; of course, the disease will be named appendicitis and this
is enough to scare a whole neighborhood, and the child will be
carted off to a hospital and operated upon for appendicitis.
If the child is left alone, given no food, and ice put on the
sensitive parts if the temperature is 103 degree F., or hot
applications if the temperature is less, the tenderness will
probably go away in two or three days; if it does not, an abscess
will form and empty into the cecum. If the child is fed, and the
tumor manipulated--subjected to unnecessary examinations--the
abscess may be made to burrow down toward the groin, which should be
avoided for it is a very undesirable complication. The first abscess
is typhlitic, the second is perityphlitic. The first may form
without the aid of bruising in the manipulation of repeated
examinations, but the second must be forced by bad management. The
latter abscess, I have reason to believe, is the former abscess
driven, by repeated manipulations, to burrow downwards instead of
opening into the cocum.
Fecal abscess, arising from ulceration of the colon, may be mistaken
for appendicitis. There is a localized swelling, immovable in
breathing or when pressed upon, and having a tympanitic sound on
percussion over it with dull sound on pressure and heavy stroke.
The symptoms of appendicitis are: Pain in the front, lower, right
side of the abdomen. It is paroxysmal and caused in the main by
peristalsis--the regular action characteristic of the sewer function
of the bowels, which is for the purpose of forcing the contents of
the intestines onward to the outlet, and which ordinarily is carried
on without pain; but, in bowel obstructions of any kind, the onward
flow of the bowel contents is cut off resulting in great pain where
there is much irritability, for irritation of any kind always
increases this expulsive movement. Food, taken in health, stimulates
this contraction and if taken when there is inflammation--enteritis,
colitis or inflammation of any part--the contraction is increased
and necessarily painful. Think of the pain that the subject of
diarrhea has, then imagine what that pain must be if there should be
obstruction so that the fecal matter could not pass. That is as near
as I can describe what the pain of appendicitis is. Anything that
will stimulate these contractions will throw the patient into great
distress. Food or drugs will cause pain, and water, the first few
days of the illness, will do the same.
In inflammation of the cecum, where the inflammatory process remains
local and there is no obstruction more than constipation will make,
the patient will be troubled with occasional attacks of pain which
will pass as colic; or there may be a diarrhea, lasting for a day,
every few weeks or months with constipation between the attacks.
These cases may lead in time to ulceration, then to fecal abscesses
and they are often diagnosed chronic appendicitis.
When the inflammation is confined to that portion of the cecum that
gives attachment to the appendix there may be no pain, or the pain
may not be intense, and because of this lack of intensity, the
patient tolerates abuse in the line of drugging and feeding until an
abscess forms, the walls of which surround the appendix which is
inflamed and often gangrenous. About this time, on account of the
gradual increase in swelling, the pressure brings obstruction,
partial or complete, causing the symptoms to become suddenly very
dangerous; then if vigorous examinations are made to determine the
exact status of the disease, don't be surprised if rupture of the
pus sac takes place! This then demands an immediate operation which
if performed will show a gangrenous appendix that had ruptured! This
is quite common and is looked upon as proof positive that an
operation was justified; in fact, the proper and only thing to be
done, and it should have been done earlier!
This is the opinion of the majority of the profession. It really
appears that surgeons are innocent of the part they play in
rupturing unsuspected abscesses and otherwise complicating this
disease by much rough handling.
The paroxysmal pain which is characteristic of the early stages of
appendicitis may be accompanied by fever, sometimes low and
sometimes high, nausea, vomiting and diarrhea. The vomiting may be
severe and there may only be nausea. If there is much vomiting there
will usually not be much diarrhea for the excessive vomiting is an
indication that there is obstruction. In other cases there is both
nausea and diarrhea; then the obstruction is either not established,
for the trouble is as yet a local inflammation of the mucous
membrane, or the diarrhea is from the bowels below the cut-off.
It is safe to prognose obstruction when the vomiting is severe; but
if the nausea continues longer than three days, it must be due to
eating or to drugs, to taking too much water while there is nausea,
or there is more obstruction than can be accounted for by such
diseases as suppurative inflammation of the cecum or appendix.
It will be well to remember that diseases of the cecum or appendix
or both never cause complete obstruction, except in exceedingly rare
cases where adhesive bands are formed, completing the cut-off. In
this connection it will be well to also remember that in absolute
obstruction the symptoms of nausea and vomiting, or retching, will
continue, while those of appendicitis will stop in three days. In
addition to the continued nausea of complete obstruction, the pulse
grows weaker and more frequent and the patient shows great anxiety
of expression, there is a sickness that can not be accounted for
with a diagnosis of appendicitis or typhlitis, and the patient has
the appearance of being desperately sick. The great pain at the
beginning subsides, the temperature falls, the pulse grows rapid and
weak, the skin becomes leaky, the mind becomes dull, drowsy and
comatose, then a little wandering and death relieves the suffering
in a short time.
These symptoms are of collapse and they may come on in the course of
a typhoid fever, or other diseases of the alimentary canal; they
always mean a fatal toxemia either from obstruction or perforation,
and occasionally the only forerunning symptom is sudden abdominal
pain. Circumstances must guide in making a diagnosis. If, during a
run of typhoid fever, there should be sudden abdominal pain followed
with symptoms of collapse and nothing to account for it, it means
perforation; an immediate operation may save the patient; nothing
else will.
A sudden pain in the abdomen of a woman during menstrual life, with
positively no unusual menstrual symptoms and no trouble in the right
ileo-cecal region, indicates perforation of the stomach or of the
gall-bladder. If there have been a menstrual period or two gone over
with a slight showing, and some uneasiness, perhaps nausea, perhaps
a flow with pain somewhat simulating abortion, a sharp, severe
abdominal pain followed with quickening of the pulse and an
exceedingly anxious facial expression, ectopic pregnancy with
rupture of the tube may be suspected. One must also keep in mind
renal calculus in determining bowel diseases.
Authors pretty generally unite in declaring that appendicitis is a
dangerous disease. In his late book, "The Abdominal and Pelvic
Brain," Dr. Byron Robinson of Chicago says, "Appendicitis is the
most dangerous and treacherous of abdominal diseases--dangerous
because it kills and treacherous because its capricious course can
not be prognosed. . . . For years I have made it a rule to recommend
appendectomy to patients having experienced two attacks. Fifty per
cent of subjects who have had one attack experience no recurrence."
In Keating's Cyclopedia of the Diseases of Children, Dr. John B.
Deaver of Philadelphia makes the following statements:
"Appendicitis, whether acute or chronic, _is essentially a surgical
affection, _and should be placed at once under the care of a
skillful surgeon. The truth of this statement is becoming recognized
in direct proportion to the general knowledge of the course and
uncertainties of the disease, and at the present time only those who
have but a limited idea of the course of the affection and have seen
but a few cases, attempt to treat appendicitis without the advice of
a surgeon."
"Operation is the only procedure by which we can be certain of
curing our patient. It is true that some cases do recover from an
attack of appendicitis without an operation, but the percentage of
those that recover from the disease is almost nil."
"The main reason, however, why the appendix should be removed as
soon as possible is that no one can state positively what course the
disease is taking."
"Although a strong advocate of the removal of the appendix in almost
every case of inflammation of that organ, yet there are a few
conditions under which I prefer to delay operation. When we find a
patient with persistent vomiting, a leaky skin, a rapid, running
pulse, a diffuse peritonitis and signs of collapse, I believe that
operative interference is contraindicated. Under these conditions an
operation would invariably be followed by loss of life. Ice to the
abdomen, calomel pushed to free purgation, a small fly-blister below
the ensiform cartilage, nutritious enemata, with stimulants in the
form of whiskey or champagne, and hypodermics of strychnine, give a
more hopeful prospect than would operation. When the peritonitis has
subsided and the constitutional condition warrants, operation may be
performed with a much better prognosis."
The symptoms described by Dr. Deaver are those of collapse,
following perforation, diffuse peritonitis to be followed soon by
death, or of narcotism--morphine paralysis, soon to be described _in
extenso _when we come to treatment.
If the doctor ever had a patient presenting those symptoms and the
patient lived after being subjected to the treatment he recommends,
it is safe to say that he was dealing with an artificial collapse--a
drug collapse--and he did not have perforation and diffuse
peritonitis.
This statement of the eminent Philadelphia surgeon adds another very
weighty proof to my oft-repeated assertion that it matters not how
eminent the medical man may be, he cannot tell the difference
between drug and pathological symptoms. Of course this is a
humiliating statement, and it is not expected that those very
eminent medical men whom I charge with inability to differentiate
between drug collapse and the collapse due to disease, will
acknowledge that I am right, for, if their mental horizons extended
far enough for them to admit it, it would not be necessary for me to
say it.
In no other way can the atrocious mistakes that doctors make in
prognosis be accounted for. _How many, many times _doctors have
declared that a given case must end in death, and they are so
cocksure that they are right that they leave the patient to die;
some sort of a fake, mountebank or fanatic comes in, the drug
disease wears off and in a few days the patient is well. That is
exactly the sort of a case Dr. Deaver describes. The faker gets busy
with drugs that antidote the morphine poisoning, and occasionally a
patient gets well in spite of all.
In regard to surgery for this disease I shall quote from Ochsner:
"Personally, I can only second the statement made by one of the most
experienced men in this country in the surgical treatment of
appendicitis, that there are thousands of surgeons who are otherwise
competent, i. e., competent to perform the ordinary surgical and
gynecological operations, whom he would not think of permitting to
open his abdomen in case he personally suffered from an attack of
appendicitis. This condition is true not because it is an especially
difficult or dangerous operation, but because it requires an
appreciation of the conditions upon which success and failure
depend, and this appreciation can be obtained only by observing good
methods.
"In many of the ordinary surgical operations it is not necessary to
follow out the details with any great degree of accuracy, because
failure to do this will at most result in confining the patient to
bed a little longer than usual or necessary, while in the
appendicitis operation it is likely to result in the death of the
patient.
"This position, when taken in the discussion of appendicitis in
medical societies, has frequently given rise to severe criticism
because upon its face it looks as though appendicitis operations
should be performed only by the few who happen to have acquired
especial skill in this class of surgery, possibly at the expense of
the lives of a number of patients.
"This, however, is not the case. The operation is simple enough if
one will but take the pains to learn it, and every town of five
thousand inhabitants should have at least one man perfectly
competent to do such work. But if there is no such man available
then I would say most emphatically that the patient's chances of
recovery are many times greater with proper non-surgical treatment
than with an operation. Of course, patients have occasionally
recovered, by accident, in the hands of most incompetent surgeons,
but the death rate after appendicitis operations in the hands of
incompetent surgeons is absolutely frightful.
"My experience and personal observation have taught me that
physicians and surgeons, as a rule, are absolutely conscientious,
and that when they perform this operation, notwithstanding the fact
that they themselves know they are incompetent (and they alone must
necessarily be their own judges as to their competency), they do it
because they have been taught that this is the only right treatment,
and that the patient is entitled to an effort on the part of the
physician or surgeon to save the life which is in danger. I believe
that this is extremely bad teaching, and that many hundreds of lives
have been sacrificed unnecessarily on account of this. I say this
because I am confident that with proper non-operative treatment
almost all of the cases which are diagnosed reasonably early may be
carried through any acute attack, no matter what its character may
be.
"I would then say, primarily, that no case of appendicitis should be
operated upon unless a competent surgeon is available. This, of
course, does not apply to cases in which a circumscribed abscess has
formed which anyone can open with safety provided he has
sufficiently good judgment not to do anything further."
Here I must differ. If the case has not been complicated by overmuch
handling, digging, punching, thumping and otherwise manipulating in
the name of bimanual diagnosis, no one has any right to put a knife
into the pus sac for it matters not how well it is done the drainage
is bad and is in opposition to the natural outlet through the
bowels. Of course if the unfortunate patient has fallen into the
hands of some one who believes it the prerogative of a physician to
manipulate in season and out of season, and who has converted a
typhlitic abscess into a perityphlitic one, or forced the pus to
burrow towards the groin, then a free opening with a let-alone after
treatment, except thorough drainage, may be followed in time by
restoration to health; however, if the patient fully recovers it
will be more from luck than from the usual management.
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.
CHAPTER V
_Symptoms: _An acute attack is ushered in with severe pain. At first
this is felt over the entire abdomen, but it is more marked near the
navel than elsewhere. After about twenty-four hours it becomes
localized in the region of the cecum.
The pain is colicky or spasmodic in character, showing that it is
due to peristalsis; food of any kind increases the peristalsis;
hence the pain becomes more severe after feeding. Do not make the
mistake of thinking that liquid food, such as milk, can be given,
for a teaspoonful is sometimes sufficient to make the patient
miserable for a whole day.
The abdomen is tender, especially over the cecum, and should
therefore be manipulated as little as possible, for it causes the
patient unnecessary pain, and if an abscess has formed there is
danger of breaking the walls which nature has thrown up.
Nature's tendency appears to be to fix the inflamed portion so as to
secure rest and this is accomplished by the muscles of the abdominal
wall becoming rigid, especially over the cecum. These muscles are
contracted to such an extent that the right thigh is often drawn up
in order to relieve the tension.
When the cecum is inflamed it is common for the colon to be loaded;
this colon obstruction prevents the onward passage of the contents
of the small intestine, and when they cannot free themselves and the
peristaltic movements meet with sufficient obstruction to force a
halt, the pain and suffering become intense. When the peristaltic
movement has met with a few disappointments it reverses and empties
the contents of the small intestine into the stomach. The result is
nausea and vomiting which at times are both severe and persistent.
But when it lasts beyond three days it is an indication of a
complication or mistake in diagnosis, providing the patient has been
properly treated.
The abdomen becomes distended with gas if drugs and food are given;
as regards the pulse, there is nothing characteristic about the
pulse rate and the temperature in this disease. Sometimes the
temperature does not go over 100 degree F., but at times it reaches
105 F. The pulse is sometimes so rapid that it is hard to count--due
usually to drug influence--and again it may not go above 100 or 110
beats per minute during the entire attack.
As these patients are nearly always constipated, and suffering from
indigestion, they generally have a coated tongue.
The above symptoms are those relied upon in making a diagnosis, and
especially the first four--pain, tenderness, rigidity, and nausea
with vomiting--which are generally referred to as the four cardinal
symptoms. Some authors give a "characteristic triad," namely: pain
with tenderness of the abdominal wall, fever, and vomiting.
A patient may have pain with tenderness, fever and vomiting, and be
very far from having appendicitis. There is a world of difference in
the importance of pain, the range being from no danger at all to
absolutely no hope. Tympanites may mean a very simple state or an
absolutely hopeless state. To be able to interpret the exact worth
of symptoms means observation, study, reflection--labor and
experience running over years--and a love of work that is not the
good fortune of a very large percentage of mankind.
Before we get through with this subject the reader will be shown how
it is possible for highly educated men to be wholly unable to
interpret the worth of symptoms.
CHAPTER VI
_Surgical Treatment: _Appendicitis is quite generally thought of as
an exclusively surgical disease. Osler recommends that such cases be
operated upon, and most of the prominent physicians agree with him.
The surgeons are a unit for the operative treatment.
Many surgeons are in accord with Prof. L. ID. Russell of Cincinnati,
O., namely, that it is not a question of "when to operate, but how
much to operate," meaning that all cases should be operated upon as
soon as possible after the diagnosis has been made, but the extent
of the operation is to be decided by the conditions found after the
incision has been made. If the appendix is surrounded with pus and
hard to get at, the indication is merely for drainage at this
operation, but if the appendix is accessible, it should be removed.
Ochsner recommends the withdrawal of all food by mouth, washing out
the stomach, leeches to be applied on the abdomen over the
inflammation to relieve pain, rectal feeding, and operation in every
case after the acute attack is over. If a "competent surgeon" is
available he thinks the proper thing to do is to operate during the
acute attack, except in a class of very severe cases, which, he
says, have a better chance to recover without the operation. I will
quote a few paragraphs from his book, setting forth his views:
"Taking into consideration the pathological conditions described,
together with the clinical experience, the likelihood of a
recurrence after an attack if no operation is performed, and the
likelihood of a complete and permanent recovery if the diseased
organ is removed under favorable circumstances, we can come to but
one conclusion, namely, that if the desired condition can be
obtained the diseased appendix should be removed."
"Except in very rare cases in which the entire mucous membrane of
the appendix is destroyed during the first attack, it is doubtful
whether the patient ever completely recovers unless the appendix be
removed. It is more likely, from an anatomical and pathological
standpoint, and certainly more in accordance with my clinical
observations, that the patient usually suffers from disturbance of
his digestive apparatus after recovering from an acute attack of
appendicitis."
" Mynter does not deny the possibility of complete recovery from
appendicitis without removing the organ, but considers it an
exception or almost an impossibility, and I find that this view is
shared by a majority of clinical observers of wide experience."
"It is rare for an acute attack of appendicitis to subside
unoperated without leaving one or more of the pathological
conditions briefly described above, and it is plain that with these
present the patient must be much more liable to a future attack than
he was primarily. In fact, many of the best observers with the
largest experience think that recurrence in these cases is the rule
and complete recovery the rare exception."
[The pathological conditions referred to are ulcerated or gangrened
appendix, perforations, fecal concretions in the appendix, etc.]
"It does not matter whether the patient suffers from catarrhal
appendicitis, with or without a foreign body in the appendix, or
whether the appendix be gangrenous or perforated, he will almost
invariably recover if from the beginning of the disease absolutely
no food is given by mouth."
"Some years ago, before I had learned to appreciate the treatment
which I now describe, I frequently operated upon patients in just
this condition, [condition of patient described as having
temperature of 104 degree F., pulse 140, abdomen very much
distended, features pinched and patient delirious], as a last
resort, thinking that this gave them the only possible chance of
recovery. Since then I have learned that this case belonged to a
class which practically never recovered after an operation, if it is
done while the condition is that in which I found this patient, and
of which a very large majority recover if the treatment is followed
which I have described."
[The treatment referred to is to let the patient alone except giving
food by rectum.]
"I have had an opportunity to observe a very large number of these
patients under this form of treatment, and have operated upon many
of them at various intervals after the acute attack through which
they were treated in this manner, and have been able to demonstrate
that the patient can recover, and practically always does recover,
if this method of treatment is employed. Of course, one occasionally
encounters a patient suffering from appendicitis who is in a dying
condition, and then neither this nor any other method is of any
value."
"I find that many authors advise rectal feeding under certain
conditions, but I am certain that the exclusive rectal alimentation
is of greater importance in the treatment of appendicitis than any
other single method, but I am equally certain that it must be
carried out thoroughly, because even a small amount of food or the
administration of a cathartic may suffice to bring about a fatal
issue."
[Why feed! There is no danger of starving!]
"I am also certain that many patients are enormously benefited by
the use of gastric ravage for the purpose of removing a quantity of
decomposing material, the absorption of which would certainly do a
great amount of harm. I am also certain that gastric lavage does
permanent good only if no further food is placed into the stomach,
which would result in further decomposition."
[At the beginning of treatment--the first visit--wash the stomach
and then feed no more.
Although some physicians boast that this is an age of preventive
medicine, the following paragraph is about all that is devoted to
this phase of the subject. In one or two places people are cautioned
not to eat too much and chew thoroughly, but what does this amount
to? How many people know how much to eat or how thoroughly to chew?
Very few physicians have a grasp of this subject.]
"It is true that recurrences can usually be prevented by careful
attention to diet, by securing daily free evacuations of the bowels,
by avoiding over-work and above all things by abstaining from eating
too freely, especially of indigestible food when tired.
Notwithstanding these facts most patients will never be entirely
well after recovering from an attack of appendicitis, and if this is
the case I believe that the best treatment consists in the removal
of the diseased appendix."
"In conclusion I will say that the most important lesson my
experience has taught me is the fact that more harm is done to the
patient suffering from acute appendicitis by the administration of
any kind of nourishment or cathartics by mouth than in any other
way, and that more lives can be saved by prohibiting this and by
removing any food which may be in the stomach at the beginning of
the attack by gastric ravage than by all the other methods of
medical and surgical treatment combined."
[This is my belief and treatment and has been since I began to
practice my profession.]
The above extracts were taken from Dr. Ochsner's Monograph on
Appendicitis.
When a patient has completely recovered from appendicitis he should
learn to live correctly. Learn to eat properly and to know how to
take care of the body in every way.
There is much to learn on the subject of what to eat, what not to
eat, what foods to combine and what combinations to shun, when to
eat, when not to eat, etc.
Appendicitis is caused by wrong eating; those who go through the
disease and recover, will have another attack unless they change
their style of eating.
CHAPTER VII
_Treatment: _I believe that contrasting treatments is the very best
way to teach; however, this plan is not so good when carried on in
writing as it would be clinically.
In order to contrast my treatment with the best just now available I
shall quote from one of the latest authorities, _"Modern Clinical
Medicine--Diseases of the Digestive System."_ Edited by Frank
Billings, M. D., of Chicago. An authorized translation from "Die
Deutsche Klinik" under the general editorial supervision of Julius
L. Salinger, M. D. Published by D. Appleton and Company, 1906.
It is reasonable to believe that when one of our leading American
physicians thinks enough of a foreign author to translate his
productions the material must be pretty well up to the top of
medical literature, and that is my only reason for selecting this
particular contribution on which to make my comments for the purpose
of contrast.
The case I select is strictly in line and parallels a case of my
own. It is a case of Diffuse and Circumscribed Peritonitis, treated
and reported by O. Vierordt, M. D., of Heidelberg.
_"Acute, Diffuse Peritonitus:_ As an introduction to the discussion
of our present views of acute peritonitis I will relate the
following clinical history:
"Case 1.--A previously healthy merchant, aged 31, was taken ill
after a few days of vague, dull pain in the right side of the
abdomen which he had disregarded, and upon the 20th of October,
about midday, he was seized with very severe pain in the right lower
abdominal region which compelled him to seek his bed; soon afterward
he had chilly sensations which increased to marked chills; there was
also nausea, eructation and vomiting, first of food and then of
bilious mucus; a little later tenesmus appeared, the patient first
voiding small, compact feces, followed by scant, thin dejecta.
Within a few hours the abdomen had become tympanitic, the pains
continued with exacerbations upon motion, after eruetations, and on
talking; the entire abdomen was very sensitive. Strangury with the
frequent discharge of scant urine was observed.
"Toward evening the physician found the patient extremely ill,
immovable in the active dorsal decubitus, with an anxious facial
expression, reddened cheeks, cautious, superficial respiration with
a low, hushed voice; he complained of continuous, also occasionally
of marked tearing and contracting pains in the entire abdomen, most
severe upon the right side low down; the temperature was 103.2
degree F., the pulse was 112, full, somewhat tense, regular and
even.
"The lips were dry, the tongue markedly coated; _foetor ex ore _was
present; painful eructations were frequent, also singultus, complete
anorexia and extreme thirst. The respirations were superficial,
quite rapid, and purely thoracic; the diaphragm was slightly raised;
the pulmonary-liver border was, in the right mammillary line, at the
lower border of the fifth rib; upon anterior examination the
thoracic organs appeared normal; the examination of the back was not
then undertaken.
"The entire abdomen was uniformly tympanitic, everywhere very
sensitive to the slightest pressure, but more so upon the right side
than upon the left. There was also pain upon pressure in the lumbar
region.
"Signs of abdominal respiration were absent. Careful palpation
showed a uniform, drum-like resistance, otherwise nothing abnormal.
The percussion note over the abdomen upon light tapping (and only
this could be borne) revealed no decided difference, and nowhere any
dullness; upon prolonged continued auscultation, high-pitched
intestinal murmurs were here and there heard.
"Retraction of the thighs produced diffuse abdominal pain, more
marked upon the right side than upon the left; careful examination
of the hernial rings gave a negative result.
"Upon careful digital exploration per rectum in the dorsal
decubitus, nothing abnormal was noted except pain in the floor of
the pelvis; the rectum was empty.
"Since morning neither feces nor flatue had been passed; the patient
complained of strangury which, however, he rarely attempted to
relieve because he feared to aggravate the pain which shot downward
and radiated into the urethra. The urine was of high color, clear,
and contained a trace of albumin and large amounts of Indican.
"The physician in charge of the case diagnosticated acute, diffuse
peritonitis, the origin of which was not quite clear; very likely it
was in the appendix. He ordered absolute rest, that the urine and
feces be voided in the recumbent posture; that, for the present,
only small quantities of ice be taken by the mouth;"
[First mistake. Never use ice nor ice water to relieve thirst for it
creates an unquenchable thirst and causes nervousness and general
discomfort, not only in this disease but in all others.]
"that two bags filled with ice be applied to the abdomen, and be
suspended from a hook if they could not be borne directly upon the
abdomen. Furthermore, at first every two hours, later somewhat less
frequently, 0.03 of opium purum in powder form was to be taken in a
little water."
[Pure opium 0.03 or 6/13 grain every two hours at first, less
frequently later, was the second mistake, for opium brings on
general depression. It not only dulls sensation, but it inhibits
combustion thereby lessening nerve supply, weakens the heart action,
and masks the physiological as well as the pathological state. The
disadvantages of such an influence should be apparent to even a
medical novice. The influence of opium in inhibiting nerve supply
reduces the normal irritability--muscular tone; this works a great
disadvantage in bringing about a tympanites entirely out of keeping
with the intensity of the disease and this is not the only
artificial symptom induced by this drug as we shall see later.
An opium tympanites causes many physicians to mistake it (a
drug-action, or a symptom induced by drug-action) for the tympanites
caused by peritonitis. The great disadvantage of thus masking and
perverting symptoms, which should be natural so that the physician
can know at any hour of the day just exactly where his patient is,
must certainly present itself even to a lay mind.
It surely is important to know that an opium-induced, phantom
peritonitis causes pressure upon the diaphragm, which in turn crowds
the lungs and heart, inducing precordial oppression--smothering
sensations and simulating important symptoms which should be
understood at once so that a proper remedy may be applied.]
_"In the following forty-eight hours,_ with irregular variations and
a slight tendency to rise, the temperature ranged between 102.2
degree F., and 105.3 degree F. The pulse became more frequent but
remained strong and uniform; the respirations were unaltered in
character but increased in frequency to 48."
[Unnatural and brought about by opium.]
"The patient, unless under the influence of opium, was sleepless,
his mind was clear, and he gave the impression of being extremely
ill, although not in collapse."
[This is peculiar to opium; it was too early for these symptoms to
develop in this case; hence drugs brought them on.]
"The pains, eructations and vomiting were decidedly relieved by the
opium;"
[A relief that was bought at a tremendous cost, for a time came in a
very few days when it was hard to tell whether the vomiting was from
the disease or from the drug. The increase in respirations was due
to opium.]
"but ice-bags for a time were not well borne and cold Priessnitz
compresses were substituted. Vomiting was rare, was invariably
bilious and coarse-grained; neither feces nor flatus were
discharged; the urine was as before the diazo-reaction negative.
"Distention of the abdomen and the area of diffuse resistance
increased; sensitiveness to touch appeared to be dulled by the
opium; in the ileo-cecal region, however, it was constantly severe
and lancinating. The liver dullness below decreased;"
[Why not? Extending tympanites caused it--insignificant at most.]
"the pulmonary-liver border extended to the upper border of the
fifth rib; on the right side of the abdomen between the navel and
the anterior, superior spine of the ileum a circumscribed slight
dullness was observed."
[This could have been taken for granted without unnecessary
palpation.]
"There was great nausea and burning thirst."
[Already the opium was getting in its work. Great nausea and burning
thirst were not due to the disease, and the crowding upward of the
liver border was caused by the gas distention.]
_"Diagnosis:_ Acute diffuse appendicular peritonitis, probably
also perforation; circumscribed perityphlitic abscess."
[The diffuse peritonitis was apparent to the eye but not to the
reason as the course of the disease proves before many days.]
"Operation was considered but not performed. Removal to the hospital
for the purpose of an operation was absolutely declined by the
patient."
"I saw him upon the following day, the fourth of the disease."
[Undoubtedly this case had advanced to the seventh day when the
description began.]
"In general the severity of the clinical picture had increased,
especially some of the individual symptoms: Severe, markedly febrile
general condition; pulse 120 to 136, moderately full, regular."
[Drugs and food caused the increase in the severity of the symptoms,
for if the increase in pulse and temperature had been due to toxic
infection, there would have been no amelioration of these symptoms,
which we find takes place later.]
"There was insomnia with occasional opium slumber; otherwise the
mind was clear but anxious. The tongue was thickly coated, the lips
were dry, there was tormenting thirst."
[Ice and opium were getting in their work, increasing the
nervousness and of course the fever.]
"The cheeks were red. The patient maintained the dorsal decubitus
with feebly flexed legs and hushed voice; the hands moved but
slightly and trembled."
[Narcotism.]
"Occasionally there were spontaneous attacks of severe, tearing,
abdominal pain, starting posteriorly in the lower right side."
[Why not? Food was being given, stimulating peristalsis.]
" The abdomen was very tympanitic and tense, and could scarcely be
touched; nevertheless, it was possible to determine upon the right
side low down an area of dullness about the size of a hand with
increased resistance; otherwise the note was tympanitic upon
percussion."
[The reader will notice the frequency of the reports regarding the
area of dullness and extension of tympanites. These frequent
examinations are wearing on patients in this condition, and are of
no consequence whatever; they start at nothing and end nowhere,
except in the discomfort and often the death of the patient; they
are practiced by too many physicians and should be discouraged for
they represent a very bad habit and are harmful; they are pushed to
a pernicious extent in some cases, for without doubt abscesses are
ruptured by them. If the physicians were not satisfied by this time
without the need of laying on of hands, observation and analysis
were lacking.]
"The diaphragm was raised; except for a small zone liver dullness
was absent."
[Of what possible benefit was this knowledge under the
circumstances?]
"Now and then there was grass-green vomitus which, the last time,
contained a few brownish granules and had a fecal odor. Urine
unchanged; micturition very painful; no feces."
[Proof positive that there was no peritonitis yet, and the
indicating symptoms were those of opium.]
"Opium at first decidedly influenced the condition; the patient took
daily 0.5 to 1.8, and since yesterday morphin subcutaneously 0.02 at
a dose."
[Of course, anyone acquainted with opium knows that it loses its
effect, but it never fails to do its damage. The daily intake of
7-3/4 grains to 27.5 grains must lead to trouble.]
"Ice bags were not well borne, and Priesslitz compresses were used
continuously. The intake of food was reduced to almost nothing."
[Not one teaspoonful of food should have been given; under such
treatment this case would have been very comfortable. Foods and
drugs were the cause of the discomfort.]
"With a sharply circumscribed perityphlitic abscess there could be
no doubt of the diagnosis of diffuse peritonitis nor of the
indication for operation on account of the long continuance of the
severe symptoms. But neither this proposition nor that of an
exploratory laparotomy, the result of which might have induced the
patient to yield, was accepted."
[It is an evidence of professional officiousness to say positively
that there was a "sharply circumscribed perityphlitic abscess." How
was it possible with meteorism as described, to say that there was a
sharply circumscribed perityphlitic abscess? It was tacitly assuming
a diagnostic skill that must test the strength of every American
physician's credulity to the utmost. The long continuance of the
severe symptoms was no fault of the disease. The worst case should
be made comfortable in three days.
Just why diagnosing a perityphlitic abscess should have cleared the
diagnostic atmosphere to such an extent as to justify one in
declaring that, _since the discovery of the abscess there could be
no doubt of diffuse peritonitis, _is hard to understand. According
to my training in the worth of differential diagnosis, I should look
upon such a diagnosis as most excellent proof that the peritoneum
was still intact, and, if the case were handled carefully, its
_intestine sacredness _would remain free from the vandalizing
influence of toxic infection.
I am not inclined to accept the diagnosis, for within twenty-four
hours the abscess broke into the cecum, and if the case had advanced
to perityphlitic abscess, the pus would have burrowed downward
towards the groin and would not have terminated as early as it did.
My reason for so believing is that we always have a typhlitic or
appendicular abscess at first; which naturally opens into the bowel,
but if the abscess be interfered with--handled roughly enough to
rupture the pyogenic membrane--the pus is forced into the
subperitoneal tissue where it may gather and become encysted, but
this is exceedingly doubtful. When the pyogenic cyst is once broken
the pus becomes diffused, and as it has no retaining membrane it
burrows in all directions, and more or less of it is absorbed,
causing pyomia.
The parts may be handled to such an extent that the abscess will be
forced to develop low down toward the groin, so low that the natural
outlet, through the intestine, will be impracticable; under such
circumstances an outside opening with drainage is the only choice in
the matter of treatment.
That the reader may understand that I have a very good foundation
for my strenuous objections to the usual _bimanual examinations
practiced upon all appendicitis cases, _I shall quote a description
of what one of America's recognized diagnosticians, Dr. G. M.
Edebohls, considers a correct examination and he declares that
anything short of such an examination is useless and untrustworthy:
"The examiner, standing at the patient's right, begins the search
for the appendix by applying two, three, or four fingers of his
right hand, palm surface downward, almost flat upon the abdomen, at
or near the umbilicus. While now he draws the examining fingers over
the abdomen in a straight line from the umbilicus to the anterior
superior spine of the right ileum, he notices successively the
character of the various structures as they come beneath and escape
from the fingers passing over them. _In doing this the pressure
exerted must be deep enough to recognize distinctly, along the whole
route traversed by the examining fingers, the resistant surfaces of
the posterior abdominal wall and of the pelvic brim. _Only in this
way can we positively feel the normal or the slightly enlarged
appendix; pressure short of this must necessarily fail.
"Palpation with pressure short of reaching the posterior wall fails
to give us any information of value; the soft and yielding
structures simply glide away from the approaching finger. When,
however, these same structures are compressed between the posterior
abdominal wall, and the examining fingers, they are recognized with
a fair degree of distinctness. _Pressure deep enough to recognize
distinctly the posterior abdominal wall, the pelvic brim and the
structures lying between them and the examining finger forms the
whole secret of success in the practice of palpation of the
vermiform appendix."_
Can there be any wonder that this disease is so fulminating in the
hands of the average medical man or can there be any surprise at the
death rate? If such an examination were given to a well man and
repeated as frequently as in the average appendicitis case, I say
that the well man would soon suffer from some severe disease induced
by bruising.
When appendicitis or typhlitis ends in an abscess, and the pus sac
is ruptured by meddlesome, unskilled treatment, scientific or
otherwise, causing the pus to burrow toward the groin, surgery is
the only treatment; there is no hope of recovery in such a case
without establishing thorough drainage, and this means skilled
surgical treatment. It will positively be a miracle if such a
patient recovers without an operation. I have seen these cases
linger for two, three, and even five years. The type of cases that
lingers so long is one that has an imperfect drainage, either into
the bowels or through a fistulous outside opening.
What per cent of cases is of this type? That is hard to tell for the
world is full of unskilled, heavy-handed manipulators.
I have seen quite a number of this type who had been brought into
this unnecessary state by bungling doctors who were treating them
for typhoid fever and its complications.
I say without fear of successful contradiction that there never was
and never will be such a case unless it is made so by the worst sort
of malpractice.
The fact that a diagnosis was made in spite of the tympanitic
distention is proof that a dangerous force was used in doing so,
converting a typhlitic abscess into a perityphlitic one, and
doubtlessly causing premature rupture into the bowel. Any
professional man, with the right regard for his patient's welfare,
and the judicial understanding that qualifies him for taking the
responsibility of directing the treatment of so important a case,
would scarcely have laid the weight of his finger on an abdomen in
such a dangerous condition. The symptoms and course of the malady up
to that time should have told the real diagnostician that there was
an abscess and that the abscess would rupture into the cecum if it
were not meddled with.
No one with a proper understanding of his responsibility in such a
case would have thought of undertaking an operation with a patient
in the physical condition that this man was reported to be in. "The
long continuance of the severe symptoms" is proof positive that the
"severe symptoms" were false or man-made.]
"Morphine was ordered subcutaneously, Priessnitz compresses to the
abdomen, pellets of ice and meat jelly by mouth; eventually gastric
ravage."
[Under the circumstances this was positively murderous.
Acknowledging to such treatment forces me to declare that the
witness is incompetent, on the ground that no one has a right to
incriminate himself. Nothing but the most positive malpractice could
have brought a case of this kind to need gastric ravage, at this age
and stage of the disease.]
_"Upon the sixth day of the disease the picture changed."_
[It is impossible for any case to arrive at this state of maturation
in six days, if allowed to take its own course.]
"The complexion became sallow, the face elongated, the eyes hollow;
the pulse was 140, small, but quite regular; the temperature was
101.3 degree F.;"
[The great discrepancy between the pulse and temperature was caused
by the opium.]
"there was clammy perspiration and a cool skin, the hands were cold;
frequently slight eructations occurred and, now and then,
ineffectual or mild paroxysms of vomiting of a greenish yellow
material with a slight fecal odor."
[All these symptoms were positively unnecessary. They were built by
food end drugs.]
"The mind was clear; there was little pain."
[There was no reason why the mind should not be clear, and there
should have been no pain after the third day.]
"The abdomen became somewhat softer, much less painful, and was
readily palpated and percussed; there was a distinct resistance
about the size of a hand, quite firm, and not fluctuating, and
accompanied by marked dullness, around McBurney's point and
downward, and only in this region severe stabbing pain; in other
areas no dullness."
[The sallow complexion, elongated face, hollow eyes, pulse 140,
temperature 101.3 degree F., clammy skin, cold extremities, greenish
vomiting with fecal odor; all these symptoms would have been ominous
of a fatal collapse had it not been that the symptoms were those of
narcotism, and not the symptoms of peritonitis as they were supposed
to be. The small, regular and frequent pulse, the clammy
perspiration, cool skin, cold hands, the eructations and mild
paroxysms of vomiting of greenish yellow material with fecal odor,
were symptoms produced by opium, food and morphine, as should have
been fully apparent to any medical mind.
If the patient had been treated rationally from the start, at this
stage of the disease he would have been as comfortable as at any
time in his life, and after the opening of the abscess, forced
though it was and followed by those symptoms, the patient still had
a chance to get well if he had been left alone. See how he responded
when given a little opportunity. Only twenty four hours after "the
intake of food was reduced to almost nothing" the abdomen was softer
and readily palpated and percussed. Just imagine, reader, what a
difference there would have been in this case if the poor, miserable
victim had been allowed the quiet he so much needed--if he had been
left without daily bimanual examinations, food and drugs. The
patient was kept in an abnormal state from the first hour that the
doctoring began to the last hour of his life.]
"The symptoms were those of moderately severe _peritoneal
collapse;"_
[In all the cases I have ever seen, I never knew of one showing any
symptoms of collapse when the abscess ruptured.]
"the prognosis was very grave although not positively hopeless."
[If the symptoms had not been those of drug and food poisoning they
were very grave.]
"Treatment: Small quantities of alcohol, to be followed by camphor."
[All the treatment necessary was absolute quiet--no drugs, no
food--nothing until nature had time to react fully; then there would
have been a full and speedy recovery. Alcohol and camphor were
injurious to a body already suffering from opium paralysis, for all
such drugs are heart depressants.
As I have said for years: The physician who gives drugs can't
possibly know where his patient is. "Peritoneal collapse!" If
there had been no narcotism there would have been no appearance of
collapse. Every symptom giving the appearance of collapse was due to
opium and morphine. I have seen such collapses for I have made them,
and I have suffered all the torments possible in this world of
medical uncertainty. For fifteen years after starting to practice my
profession I labored hard with symptoms of my own making. After drug
action and symptoms were once developed, I knew nothing more about
my patients; it is true I guessed, and theorized, and reasoned, but
in truth I did not know positively just where my patients were. I
consoled myself in those days with the thought that some day I
should know; I believed that the fault was with me, that I was
lacking in diagnostic ability, and that by hard work the time would
come when I could read disease by its symptoms as well as the best,
for I then thought the big men of the profession knew everything
they pretended to know This was my ambition, but the ability to size
up symptoms under given conditions and tell their true worth forever
eluded me and kept me in a state of unrest and discontent that was
next to ruining my life. If light had not come when it did I should
have abandoned the profession, but it came accidentally; it could
not come otherwise for I did not know how to look for it. In the
course of time I stored in my memory many cases that from accident
or caprice had recovered without drugs and food. The satisfactory
advance made by sick people, suffering from different diseases, when
they were left without food or drugs, occurred so often, and with
such unvarying regularity that it ceased to be a coincident--it was
absurd for me to continue to explain the results by the hackneyed
word "coincident," a word that is usually loaded with a lot of
dogmatism, idleness and selfishness.
When I accepted the changes, taking place _without medical aid,
interruption and interference, _as true cures, and so much a part of
nature, and so intimately blended with the fixed laws of nature that
like results could be looked for with the same degree of certainty
that we look for the rising or setting of the sun, I busied myself
in formulating a plan of cure as nearly in accordance with natural
laws as I could. I am now, and have been for twenty years,
developing in this line, and I have gone far enough to declare that
I have watched symptoms start, mature, and decline, and in this way
have learned, by contrasting the symptoms in a given ease that has
not been medicated, with those of a similar case that has been
medicated, to know the full value of symptoms under medication, as
well as the full value of the symptoms when not under medication.
This knowledge I am using in analyzing this medical classic and from
my standpoint I can see how very easy it was for the author of the
article under consideration to blunder along as he did. The doctor
should not feel lonesome, however, for he has a world of company.]
"This condition lasted nearly twenty-four hours; then a very large
and hard stool, followed by a thin one of hemorrhagico-purulent
character was discharged and simultaneously a decided change took
place. The appearance and pulse improved; the abdomen became softer
with the exception of the marked resistance upon the right side low
down, and the fever slightly remittent, its maximum 101 degree F.
Vomiting did not recur; the patient moved about somewhat in bed and
slept several hours in a half-lateral posture. Meat jelly and cold
beef tea were swallowed."
[This feeding was the beginning of mistakes for the second round. If
this patient had been left distressingly along until he could have
thrown off his opium poison and become normal, and allowed the
abscess to drain and close, all would have been well. This, I
assume, would have been the ending if the vigorous examination that
was given the patient the day before the collapse had not
prematurely ruptured the abscess both into the gut and into the
subperitoneal region converting an appendicular abscess into a
perityphlitic one.]
"Upon the next day there were several hemorrhagico-purulent stools,
the urine was profuse and voided without pain. Nevertheless, firm,
flat resistance was still felt in the lower right side and upon
pressure there was lancinating pain no fever."
[What was the need of this everlasting, eternal, never-ending
manipulating to find how much induration there was? Nothing but harm
could come from such senseless officiousness. The punching, feeling
and manipulating of patients without a reasonable excuse is a very
bad habit, one that is peculiar to young and inexperienced men.
There is no reason, no object, no purpose in it; it is just a bad
habit.]
"There could be no doubt that the perityph abscess had ruptured into
the intestine, and that in consequence of this the diffuse
peritonitis had at once been relieved."
[There was no peritonitis up to this time, except the small portion
that represented the peritoneal covering of the organ or organs
involved in the primary infection. The peritoneal cavity, or the
peritoneum as an organ, was not involved in this disease; hence it
is an error to say that there was diffuse peritonitis which was at
once relieved by the rupturing of the abscess into the intestine. It
is worth something to know the difference between a drug-created
_phantom _peritonitis and a true peritonitis. It is not for the sake
of controversy that I am taking exceptions to the opinions advanced
in this case, neither is it because I delight in criticizing,
differing from or finding fault with authority; I have a more
laudable reason--one that I consider humane and justifiable--namely,
to point out to the few who happen to read this book, a safe and
life-preserving plan of treating one of the most talked about, and
(because of bad--decidedly bad--treatment) one of the most fatal
maladies of this age. To do this it is necessary to point out and
teach these few how to reason on the subject, and how to weigh with
something like exactness the various important symptoms that present
themselves under varying styles of treatment.
If a young physician is guided in his opinions by authority--if he
believes that the last word has been said, because he has the last
book from the leading authority, and if said authority has not yet
learned that there is a true and a phantom diffuse peritonitis, said
young man is not in line for saving life; on the contrary, he is
liable to mismanage and meet with as great a failure, and be the
cause of as unnecessary a death as was the good doctor from whom we
are quoting and of whose _medical sophistry _I am trying to give the
true qualitative and quantitative analysis.
Rupture into the gut is exactly what will happen every time, in all
cases, if left alone and no food nor drugs given.]
_"Treatment: _Warm, followed by hot, flaxseed poultices; rest,
freshly expressed meat juice or beef tea, in all 200 grams; thin
gruel made with milk, 200 grams; wine, 100 grams in twenty-four
hours, small portions to be taken every two hours; no drugs."
[A little over six ounces of meat juice and six ounces of gruel made
with milk! The starch contained in the gruel will always create gas
in these cases and stimulate peristalsis; the gas inflates the cecum
and drives the contents of the bowels into the abscess cavity; this
sets up secondary inflammation. The meat juice and wine could have
been left out to the patient's betterment. It is refreshing to know
that no drugs were given, and if the case had been treated from the
start on the no-drug plan the course and ending would have been very
different. The poultices would have done as much good if they had
been put on the leg of his bed, and much less harm.]
"This improvement continued for several days and even became more
marked The abdomen returned to the norm with the exception of the
ileo-cecal region; there was a small stool daily without
recognizable pus; no fever.
"Upon the_ twelfth day of the disease vomiting _suddenly recurred
with severe diffuse abdominal pain, marked meteorism, and fever to
about 102.2 degree F.;"
[True, diffuse peritonitis set in at this time.]
"the symptoms increased in severity, and changed during the
collapse, his temperature 97.3 degree F., pulse 160, thready,
uneven; conspicuous facies hippocratica; no pain; a slight comatose
condition, moderate meteorism, no movement of the bowels. Stimulants
were without effect; subcutaneous saline infusion revived the
patient but only for a short time? and death occurred the following
morning upon the fourteenth day of the disease."
[Meteorism! What at is it? A blown-up condition of tile bowels.
Gruel caused gas to form the gas was driven into the abscess cavity,
reinfection took place? which ended in diffuse peritonitis. The
patient's resistance was used up and, being exhausted he died. He
had made a brave fight a against all sorts of odds but the second
round was too much for him.]
_"Autopsy:_ Normal condition of the scrosa above the omentum: the
appendix surrounded by adhesions embedded in fecal pus? gangrenous
toward its terminal portion, and showing perforation; fecal calculus
in the pus; appendix movable toward the cecum."
[Just what may be expected in all cases! Nature is always busy
reinforcing weak points, but the modern physician and surgeon is too
wily and artful for her; she can't always anticipate his moves,
hence she can't always fortify successfully.]
"Agglutinated point of rupture at the median periphery of the cecum
near the ileo-cecal valve. The perityphlitic pus appeared to be
sacculated by adherent intestinal coils, but beyond the adhesions in
the free abdominal cavity below the omentum there was diffuse,
fresh, fibrinous peritonitis and distributed here and there small
quantities of thin, putrid pus (many bacteria, large quantities of
streptococci and cold bacilli). The peritoneum was injected. of a
delicate rose-red color, here and there covered with fine,
mucus-like pseudo-membranes. Heart flabby."
[The autopsy showed nothing more than would be expected. The fresh
peritonitis confirms what I say that a reinfection was forced
because of the character of the food. The meteorism opposed
relaxation and rest, two conditions positively necessary and without
which healing can not take place. What was to hinder the heart from
being flabby, Drugs and systemic infection are quite enough.
In proper hands this young man would not have been very sick;
possibly his trouble would have been thrown off and the inflammation
passed off by resolution.
The following should be of interest for it is a very _scientific
explanation _of how the young man came to die:]
"The clinical history is in every respect typical and instructive.
"It shows us that the origin of peritonitis which is by far the most
common, is in a diseased appendix. At the autopsy this was found
necrotic and perforated. It is questionable whether the perforation
existed from the onset of the disease; it is possible that at first
an ulcer extending to the serosa caused an infection of the
peritoneum; at all events this occurred acutely, and produced the
sharply defined disease."
[I agree. The perforation brought on the relapse and the collapse.]
"The clinical abdominal symptoms in the first period of the malady
pointed to the fact that at the onset there had been a diffuse
inflammation of the peritoneum, and that later, by the adhesions to
the appendix which were found at the autopsy an early encapsulation
of pus had taken place in the ileo-cecal region; this produced a
purulent softening in the wall of the cecum and led to the favorable
rupture of pus into the intestine and to an immediate amelioration
of the acute peritonitis. The point of rupture, however, then
closed, and partly perhaps to the action of fresh infectious and
toxic material, perhaps only to the perforation of the appendix, may
be ascribed the exacerbation of the peritonitis, that is, a renewed
attack which caused the death of the patient."
[The symptoms were those of intestinal putrefaction with local
inflammation of the cecum and, as the history of the ease has
pointed out, was located in that part of the cecum giving attachment
to the appendix, for the autopsy showed that the appendix was
surrounded by adhesions and imbedded in fecal pus. Please note
particularly: The appendix was found in a pus cavity--a
perityphlitic abscess. Why shouldn't the appendix be necrosed?
Located in a field of inflammation, blown up, distended beyond its
vital integrity; why should it not become gangrenous, It doesn't
matter when the perforation of the appendix took place for it is
quite evident that there was not enough disease of the appendix to
cause its perforation until after it had become encased in the
abscess cavity, and if the young man could have been freed from the
treatment he received and could have been given the necessary rest
the abscess cavity would have emptied itself, necrosed appendix and
all, into the bowel and he would have made a perfect recovery.
"The point of rupture closed!" How could a rupture into a distended
gut close, The distention was greater after the rupture than before.
Fresh infection could not take place without a power to force the
putrefaction greater than the force that existed before the abscess
broke into the cecum. Let us reason together: Nature fought
successfully against heavy odds before the rupture. There was gas
distention of bowels interfering by pressure with the circulation
and increasing the area of destruction of tissue; frequent retching
and vomiting interfering by stretching and probably tearing,
threatening disruption to the plastic process that was going on to
close in the disorganizing and necrosing processes; the frequent
examinations, and manipulations for diagnostic purposes, etc., but,
in spite of all this opposition, fatal infection was successfully
resisted; then, after the rupture and discharge, the relaxation, the
calling off by nature of all her defenses, showed that the battle
was won. All the defense yet left was the hard induration, "firm,
flat resistance." This induration was quite sufficient to prevent
reinfection, had there not been something out of the regular order
to interfere. In this case there was a prostrated muscular system.
The narcotic had left the patient without muscular power. The
starchy food created gas, and the bowels, not having their natural
tone, gave way to the gas until there was _"Meteorism,"_ not
tympanites but meteorism which means to blow up or distend all that
is possible.
Such a state as that means mechanical interference with every organ
in the thoracic, abdominal and pelvic cavities, and, besides the
pressure and interference in drainage and the blowing into the
abscess cavity and into the pyogenic membrane gas loaded with
infection, there was an almost fatal interference with the action of
the heart and lungs. The prostrating effect on the muscular system
of the septic or putrefactive poison was nothing to be compared to
the paralyzing effect of opium. I believe this man would have
survived every interference if the milk gruel had been left out, but
acting as it did, it proved to be the last straw.]
"In regard to the fulminant symptoms at the onset of the disease,
however, it is more likely that even then perforation had already
occurred, and I that the final and fatal exacerbation was in
consequence of adhesions formed in the first period which were
powerless to resist the entrance of organisms producing
inflammation. The pus finally broke through the adhesions, and
produced diffuse peritonitis."
[It is a technical point unnecessary to raise whether the adhesions
formed in the first or the last period; they were formed without
question; I and if they were formed in the beginning, as doubtless
they were, they withstood the most severe and trying period of their
existence, which was before the abscess broke into the bowels, and
so far as being able to resist to the very last, there has been no
evidence to prove that the last infection was because of any lack of
power of resistance on their part for the autopsy showed them
intact. It is doubtful if anything but sound tissue could have
withstood the strain that was put upon this man's diseased cecum
from gas distention. The infection-laden gas could find a way
anywhere in diseased tissue and broken continuity. Why should the
pus break through the adhesions and find its way into the peritoneum
after they had been able to make an effectual resistance till the
bulk of it had forced a passage into the bowel? Why should the
adhesions have less power to resist when there is less strain upon
them and also a patent outlet for the pus? I fear our German friend
of "Die Deutsche Klinik" had "booze" in his logic when he was
explaining how his patient came to die.]
"Moreover, the bacterial finding of streptococci and cold bacilli in
the perityphlitic abscess is typical, and the limitation of the
diffuse peritonitis to areas below the omentum is also instructive.
This simultaneously prevented the invasion of organisms producing
inflammation into the serous surfaces above."
[There is nothing strange about this for nature works for the
purpose of preventing "serous surface" invasion, and it takes a
deal of malpractice to force such an infection. If nature's
provisions against peritoneal inflammation were not as great as they
are, few people with intestinal putrefactive diseases, from cholera
infantum in babyhood to proctitis in old age, would get well, for
most of the treatment for one and all of these diseases is
obstructive rather than conservative and helpful.]
"This strong man, aged 31, had previously regarded himself as
perfectly well. Nothing indicated the danger in which he found
himself and which had existed since the appearance of the fecal
calculus. the time when this had formed being impossible to
determine. The disease appeared acutely with fulminant symptoms."
[He was, indeed, unfortunate, but his greatest misfortune, as I see
it, was his treatment. Every acute disease is fulminant, even
indigestion is fulminant, but the force of the warring elements is
soon expended and unless reinforced by fresh elements the
fulmination must end.
In diseases such as typhoid fever, appendicitis and typhlitis, we
have first of all a constitutional derangement brought on by errors
of life. The general resistance is lowered from nerve-exhausting
habits; the general tone of digestion is below par and the bowel
contents are maintaining a higher toxic state than usual; we have
added to this condition an unusual tax in a long run of hot weather,
business worries or unusual mental, physical or digestive strain,
following which acute intestinal indigestion manifests with a sudden
explosion; or there takes place a transformation of the contents of
the bowels into an intense putrefaction which infects a portion of
the mucosa that has been rendered susceptible by pressure from fecal
impaction, concretions, or any cause capable of devitalizing. If the
infection takes place in Peyer's patches, typhoid fever is the
consequence; if the local trouble is of the cecum, typhlitis will
result, and if the local devitalization is in the appendix, brought
on from the irritating effects of a fecal calculus, appendicitis
will result.
These diseases may start in a fulminant manner as suggested--with an
acute intestinal indigestion, which will die down as soon as all the
elements that combine to set off this fulmination l eve expended
their force and unless fresh material be added everything must
settle down to a local trouble. Or if the primary irritation is
subjected to a light form of toxic infection the development of the
disease will be much more insidious and will require much more time
to come to its maturity, or its fulminating stage.
The reason for this is that each person has a cultivated immunity to
a given toxic state of the intestinal contents, and when from
pressure or the irritation caused by a calculus. there is a
denudation of the mucosa the infection that takes place has not the
power to arouse a systemic resistance' but can cause only a local
inflammation; this inflammation may end in ulceration, or it may
cause a thickening of the parts and interfere with drainage from
mucous or glandular pockets; then the locked up secretions become
intensely toxic, and this sets up a new infection much greater then
l the first and powerful enough to cause the system to call out its
militia to put down the rebellion. Now we have fulmination, but if
food and drugs are withheld it ends soon.]
"Severe abdominal pain with tense abdominal walls, fever and
vomiting form the characteristic triad in the first phase of the
disease; less rapidly does meteorism appear. This depends upon
whether the inflammation of the serosa quickly spreads or remains
local. Peritoneal meteorism is peculiar. The abdomen is uniformly
distended, balloon-like; the muscles as well as the rest of the
abdominal walls are tense. It must be added, how ever, that in spite
of the excruciating pain upon touch there is no sign of contraction
of the abdominal muscles, of the "muscular resistance" _(defense
musculaire) _which is so common on pressure in other forms of
abdominal pain, particularly when circumscribed."
[Distention from any cause--or stretching of muscular fiber--causes
paralysis for the time being.]
"The same is true of the diaphragm; it is forced upward, the muscles
are therefore elongated and tense; but there is no evidence of
active contractions. Abdominal respiration ceases; gradually then,
as may be recognized by the limits of percussion, increasing loss
of _muscle tonus_ is added. In this case the autopsy showed that the
peritonitis had not advanced up to the serosa of the diaphragm."
[The muscle tonus when a patient is under the influence of opiates
cannot be reckoned with, for that drug paralyzes the muscles, and
the bowels fill with gas as was seen in this case up to the day
before the abscess ruptured; on that day feeding had been suspended,
resulting in a decrease of gas and an amelioration of all the
symptoms.]
"Among these signs pain, either spontaneous or upon touch, a rise in
temperature, increased frequency of the pulse and, in general, the
signs of severe illness, are to be looked upon as the local and
general symptoms of a severe septic inflammation; vomiting, at least
in the first stages of peritonitis, was due to decided reflex
irritation of the numerous branches of the peritoneal nerves; the
fecal discharges at the onset may be explained, but by no means
invariably, as due to peristalsis acting reflexively. The
constipation which followed this, however, as well as the meteorism,
must be attributed to a hypotonia and paralysis of the musculature
of the intestine by collateral edema."
[Beautiful sophistry. Words well woven together are captivating and
frequently dethrone reason. If I didn't happen to know better I
might really believe the author of this contribution to medical
science knew exactly what he was talking about.
The constipation in such diseases as this is caused by the fixing,
or natural resistance to motion, which is always to be found in
diseases of tile bowels and is one of nature's conservative
measures. The hypotonia or paralysis of the musculature was brought
about by the opium; and it is certainly strange that educated men
can build a symptom or condition by the administration of drugs and
yet remain absolutely unconscious of the part they are playing, and
proceed to build a beautiful theory explanatory of results.]
"The excessive abdominal pain, increased by movement and on the
slightest pressure, caused the patient to remain motionless upon his
back and to avoid the slightest movement of the abdomen either by
speaking or coughing."
[This is a characteristic symptom when there is great distention of
the bowels.]
"At the start the temperature was uniformly high, but later
remissions in the pus fever were recognized."
[All fever would have disappeared had it not been that the
intestinal putrefaction was kept alive by feeding.]
"The pulse from the onset was comparatively frequent, regular and
somewhat tense.
"The vomitus was at first composed of the gastric contents, the bile
of a peculiarly pure, grass-green, biliverdin color mixed with a
yellowish chyme-like material, and in the later stages of the
disease showed thin masses having a fecal odor_ (ileus
paralyticus)._ In regard to the dejecta, the two passages at the
onset of the disease pointed to increased peristalsis; this was of
short duration, soon changing to the opposite condition, and until
the rupture of the perityphlitic abscess absolute constipation
existed."
[The vomiting would have gone to stay within three days if no drugs
nor food had been given; as it was, when real vomiting ceased the
opium nausea began.
This patient was not allowed to come into that state of peristaltic
elimination that is due in all cases in three days at the farthest,
and which would have come to this man if food and drugs had been
withheld.]
"Pain upon urination and strangury was due to inflammation of the
peritoneal coat of the bladder, in which a noticeable irritation was
produced by slight distention as well as by contraction of the
bladder. The albuminuria was the well known infectio-toxic 'febrile'
form; indicanuria was in proportion to tile fecal stasis.
"In the course of the next few days a new symptom was added to this
group: Exudation, which was demonstrable both by palpation and
percussion. It was the natural consequence of inflammation of the
peritoneum, and was both of diagnostic value as indicating general
peritonitis and of special value in that, more definitely than the
pain, it pointed to the original seat of the affection, which,
according to present indications, could only have been an internal
incarceration following right-sided inguinal hernia, or femoral
hernia, or appendicitis. As neither the history nor the general
status (normal condition of the hernial rings) furnished any points
of support for the first view, only the diagnosis of appendicitis,
that is, of perforation of the appendix, could be made with that
degree of certainty attainable in diseases of the abdominal cavity
in general.
"After the appearance of these symptoms, a more or less firmly
adherent but limited perityphlitic abscess, and a less intense
although well developed peritonitis in this region, were assumed;
the latter, notwithstanding the painful meteorism, was not
necessarily diffuse in the strict sense of the term; the omentum
often protects the upper abdominal cavity from infection, as was
proven in this case at the autopsy. It is possible that this diffuse
peritonitis, which did not in the early period of the affection
extend beyond the limited local focus, was not due to the intestinal
contents and to bacteria, but chiefly to bacterial toxins which
arose from the circumscribed original focus. This fact is pointed
out by the prompt retrogression of the diffuse peritoneal symptoms
after rupture of the abscess; the diffuse peritonitis of this stage
might then be designated a nonbacterial 'chemical' inflammation,
according to the terminology now in vogue; finally, it was
positively a bacterial infection, although the postmortem finding of
bacteria in the distant folds of the peritoneum is not proof of
this; we know that during the terminal agony or after death these
may wander a long distance from the perityphlitic focus."
[The author plays so fast and loose with the words, "diffuse
peritonitis," that I am reminded of a remark made to me several
years ago by a society lady who posed as a pace-setter in all
matters pertaining to the intricacies of what one should and should
not do. The subject was one that I did not know much about at that
time, and upon which I am not much better informed at present. It
was on diamonds. I complimented her on a very beautiful sunburst.
She took the compliment modestly, of course. The center diamond was
large and, I thought, of uncommon brilliancy, and I remarked, "That
center stone properly mounted would make a very fine solitaire." She
then informed me that she once owned a _cluster of solitares._
The author tells us that at first the diffuse peritonitis probably
did not extend beyond the local focus; this of course is exactly
what I am contending for from first to last and I insist that there
was not peritonitis proper until the occurrence of the fatal
relapse.
It is somewhat surprising that this article should be selected to
represent the last word on this subject, when the author builds his
treatment upon diffuse peritonitis; then enters into a lengthy
analysis and explanation of symptoms to fit the diagnosis and
treatment and before he is through with the subject he declares that
the _diffusion is confined _to the focus of infection.
If I did not know something of the worth of words I am not sure but
such an excellent explanation might persuade me!! If I did not know
from experience that all this is _theory, beautiful theory, _it
might be very hard to resist!]
"After the symptoms of local and general inflammation with their
secondary signs in the stomach and intestine had lasted for six
days, suddenly a complete change took place: The nervous, anxious,
extremely distressed patient became feeble and scarcely complained
at all; his formerly congested face was pale and elongated, the nose
pointed and cool; the skin lost its turgescence and warmth and was
covered with a cold sweat; the bodily temperature also fell, the
pulse became small and frequent but remained quite regular, the
abdomen became softer and to a great extent lost its sensitiveness;
the vomiting decreased to a few painless attacks,"
[Wholly due to the opium and morphine given]
"and singultus disappeared: A picture which, to a certain extent, is
a combination of collapse and narcosis although not to the degree of
profound loss of consciousness, being the picture of an intoxication
in sharp contrast to the preceding febrile state."
[That is exactly what I stated above--a case of narcotism. How is it
possible that the author, recognizing the narcotism, feels it
incumbent to give other explanations?]
"Just as the affection had suddenly developed to its full height at
the onset of the disease, and much more swiftly than, for example,
is the case in phlegmon of the external walls, so with extraordinary
rapidity did the clinical picture assume a new type. In this respect
we must consider the very great area of the peritoneal folds, their
numerous lymphstomata, and their intimate relation to the
circulation, and we are impressed with the fact that fluids and
solubles, as well as formed products, are rapidly absorbed by the
peritoneum.
"Somewhat less rapidly than this, but nevertheless in the course of
a few hours, another change took place, a favorable turn following
the rupture of pus into the intestine. Here we were dealing with a
well known and familiar phenomenon; if this occurs in the peritoneum
the effects are particularly well marked; similarly as in the case
of a phlegmon which rapidly disappears with the discharge of pus
even although the inflammation extend beyond the pus focus, the
symptoms of diffuse peritonitis promptly disappeared after the
rupture. Very likely, as has already been stated, the symptoms of
diffuse peritonitis in the first stages of the disease are to be
referred to a chemical inflammation of the serosa, i. e., one due to
toxins and without the ingress of bacteria; and it must be
remembered that the clinical picture of this chemical peritonitis
cannot be differentiated from that of the severe bacterial form.
With the rupture of the abscess, the entrance of poisons into the
free peritoneal cavity, and their resorption by the extensive
peritoneal surfaces, as well as the vomiting and the intestinal
paralysis, ceased. The taking of nourishment again be came possible.
"The point of rupture formed adhesions, the natural drainage of the
peritoneal ichorous focus ceased, perhaps a new influx of
inflammatory material from the perforated appendix also took; place.
There was a fresh relapse of the local peritonitis which extended
beyond the boundaries of the limiting adhesions, and permitted the
invasion by bacteria of the free abdominal cavity. This, time the
severe toxic picture of collapse immediately followed, and with
marked decrease in cardiac strength led to death.
"Doubtless the patient might have been saved in the first stages of
the disease by the evacuation of the abscess; the incision would at
first have acted similarly to spontaneous rupture into the
intestine, but the relapse would have been prevented by permanent
drainage, and a radical cure might have been brought about by the
immediate or subsequent removal of the appendix.
"Opium, no doubt, had a favorable effect upon the affection. By
relieving intestinal irritability, and by bringing about a mild
degree of narcosis, the patient was kept quiet and this materially
assisted in limiting the severe perityphlitic suppuration in the
first stage of the disease."
[All of which is positively not true, as I have witnessed for
years.]
"If, as it unfortunately happened, the point of rupture had not
immediately closed again, if it had remained open until suppuration
ceased and contraction and healing of the perforated appendix had
taken place, opium would have been regarded as instrumental in
saving the patient, and unquestionably, at least to some extent,
justly so. Among other factors in the treatment, the relief to the
intestine by the suspension of nourishment was of paramount
importance. The subcutaneous saline infusion had an obvious but,
naturally, only a transitory effect."
The subcutaneous saline infusion is another ridiculous habit. It
would really be amusing if it were not so tragic, to see patients
driven to the edge of the great divide and then see the innocent
doctor throw out an impotent life line.
The absolute innocence displayed by this professional man, from
first to last, his belief in himself and the mechanism of his theory
and practice exculpate him from the charge of carelessness, neglect
of duty or even that he didn't know what he is doing. He does know
what he is doing in a way. He works as exactly as a Waltham watch
and he thinks about as much as the stem that winds the watch.
I cannot agree to the summing up of this case. There was not at any
time, previous to the relapse and death of this patient, what we
understand as peritonitis. A post-mortem examination might have
shown the intra-peritoneal covering, of that portion of the cecum
involved in the inflammation, slightly inflamed, but it is not
reasonable to believe that the inflammation was of a toxic character
unless adhesive inflammations can be so called.
Inflammation is always the same, it matters not what the _exciting
cause _may be. It is an exaggerated physiological process. If there
is inflammation of any part of the body it means that there is an
exaggeration of function. Its intensity will be in keeping with the
exciting cause. If the cause is intense heat or cold, or a corroding
acid or alkali, the local action may be great enough to destroy the
part; the inflammation following will be of the contiguous structure
outside of the killing range of the cause, and it will be a
simple--non-toxic--inflammation unless the secretions thrown out in
excess of the reparative need are retained by dressings or prevented
in some other way from draining away. If these secretions are kept
bound on the raw surface by dressings until they decompose--yes,
until the fermentation causes germs--the wound will become infected,
and to what extent will depend upon the amount of
malpractice--carelessness or ignorance--to which the case is
subjected.
If the inflammation is caused by decomposition or a toxic agent, the
extent of the process will depend upon the integrity of the part
infected and the state of the general health, also upon the local
environment--such as pressure interfering with the circulation of
the blood.
In this fatal case there was the constitutional derangement and the
toxic state of the alimentary canal; then there was the exciting
cause, sufficient to create a local infection the symptoms of which
were given at the beginning of this description, and which lasted
for a few days; during which time the patient, no doubt, was eating
and possibly taking home remedies to move the bowels, etc. These
preliminary symptoms were followed by a severe pain in the right
lower abdominal region, followed with chills, fever, nausea,
vomiting and later by painful movements from the bowels, small in
character, and soon after this distention of the bowels from gas.
During the few days of preliminary symptoms nature was going through
the usual preparation of fixing the parts. The muscles were becoming
rigid, which is one of nature's plans for protecting an inflamed
part; the infection was striking deeper and arousing all the
defenses. Possibly there had been a local inflammation of long
standing, gradually degenerating into a fecal ulcer, which means
that there was a spot of ulceration deep enough for fecal
accumulation and the accumulation created fresh infection, which
lighted up an active inflammation setting all the parts into
defensive activity. The muscles of the abdomen--the bowels and all
involved and contiguous parts--became set or fixed; and when this
rigid state became established, the bowels below the cecum refused
to receive the contents of the small intestine; hence when the
peristaltic movement started at the head of the small intestine it
found that an embargo had been laid on the cecum and lower bowels so
that nothing could pass. This embargo took effect "about midday; he
was seized with very severe pain." What was this pain? What is the
pain that always attends obstruction of any kind? It is the desire
for the bowels to move when they are unable, on account of the
stoppage, to do so. Is there a reader who can't conceive of the
terrible suffering that must come from such a state of the bowels,
The pain is not from the spot inflamation, or ulceration, or the
forming abscess, whichever is the exciting cause of all this
trouble; for, if it wore, the pain would not stop in three days, or
after the patient has been fasted long enough for the peristaltic
movements to subside side. No, the local inflammation is not
sufficient within itself to cause any more pain than this patient
had the few days before he went to bed; it takes obstruction to
bring suffering, and even obstruction will not cause pain _per se,
_for this is proven in all cases rightly treated. As soon as the
stomach and upper bowels are rested from food and drugs, all pain is
gone and will never return unless the patient is badly handled.
In this case opium and morphine were given; this was very bad
treatment, for these drugs always produce nausea and vomiting,
exactly what was not desired because of the evil effect the retching
had on the forming abscess. It is true that these cases frequently
vomit the first three days after the obstruction, but there is
practically no danger from retching that early in the disease.
Again, the opium masked the case dreadfully; for it produced
vomiting at that stage of the case when there should have been no
trouble with the stomach at all, and induced a tympanites that was
mistaken for the same state brought on by peritonitis.
In this case the doctor was in a mental mist from the beginning to
the end; notwithstanding he was so confident that he knew all about
his patient, that he has given the case a careful summing up so that
it may be put with the medical classics.
The doctor is in error when he gives the name of "Acute, Diffuse
Peritonitis." The case could not have been peritoneal perforation at
the start, for the symptoms do not justify the diagnosis. A
perforation causing diffuse peritonitis so early would have a higher
pulse and temperature, and death would have followed within a few
hours.
I can believe that there might have been an ulcer extending to the
peritoneal covering, and this set up local peritonitis; but there
was not at any time before the fatal relapse, a toxic inflammation
within the peritoneal cavity; hence there was not diffuse
peritonitis, and there could not have been without complete
perforation which would have ended the case in death very soon.
In this case the point of infection was walled in, as all such cases
are, with exudates and whether the appendix was primarily affected
or not doesn't matter; it was within this enclosure and found to be
ruptured, which is common; but its rupture was of no consequence
because the escaped contents were in the abscess cavity that finally
emptied into the cecum, the natural outlet in all these cases if
they are left to nature and not officiously fingered--thumbed and
punched to death.
The distinction drawn by this author between toxic and bacterial
peritonitis is, to my mind, a distinction without a difference.
In this case the tympanites following the obstruction was due to the
fact that the gas in the bowels was retained for a few days because
of the completeness of the obstruction, and would have passed off in
three days had it not been for the paralyzing effect of the opium;
hence the distention that came from gas was succeeded by the
distention peculiar to opium and caused the doctor to believe that
he had a case of diffuse peritonitis when, in fact, he had a case
of gas distention due to morphine paralysis. The morphine directly
and indirectly weakened the heart. The distention of the bowels was
a constant interference. The pulse at the start was fine at 112, but
in six days it had increased to 140 and finally reached 160.
CHAPTER VIII
The following case comes to my mind, for some of the initial
symptoms are similar to those of the case just described: M. B., age
42, farmer, was taken sick with the usual symptoms of appendicitis
as near as I could get the history from his wife, who was his nurse.
He lived twenty miles from Denver. When he was taken sick he called
a local physician who treated him for _bilious diarrhea. _The drugs
used, as near as the wife could remember, were small doses of
calomel followed with salts to correct the I liver, morphine for
pain, and bismuth and pepsin for digestion and diarrhea, and quinine
to break the fever; also hot applications on the bowels.
The pain was so great that morphine had been given quite freely. At
the end of one week the sick man, being no better, declared that he
would go to Denver and consult another physician. When he told his
physician what his intentions were, the doctor advised him not to
attempt the trip himself, for he was too sick, but to send for the
physician. The sick man was willful and forceful, and he was also
afraid of the cost; and, being a plucky fellow, he declared that he
could go just as well as not and that he would and he did.
His wife was a large, strong woman and gave him valuable assistance,
but I never have understood how it was possible for so sick a man to
make the journey from his home to my office. He was obliged to help
himself a great deal in climbing in and out of ordinary conveyances
to reach the train and, when in Denver, with his wife's assistance,
he walked a half block to the street car; then from the car to my
office he was obliged to walk one block and at last climb one flight
of stairs. When they came into my office the wife was almost
carrying him. I saw at a glance that he was a desperately sick man,
and before I attempted to examine him I had him lie down for a
while.
He had no history of any previous sickness; he had always been very
healthy, and his life had been spent in hard work in the open air.
The general appearance of the man was that of one suffering from
diffuse peritonitis. The abdomen was enormously distended; this
symptom more than any other caused me to fear and wonder--fear that
rupture would take place before he could be put to bed, and wonder
how it was possible for a man to be out of bed and go through what
he had gone through that morning without causing a fatal injury of
some kind. The distention, I was informed, had been gradually coming
on from the first, and he had been given morphine to control the
pain from the first day of his illness. When they gave me this
information I knew that the tympanites was due to narcotic
paralysis, instead of coming from perforative, septic peritonitis,
as the general appearance and symptoms indicated. This reasoning
gave me hope in spite of the formidable appearance of the case.
The pulse was 130, temperature 102 degree F., in the forenoon; he
had been troubled with nausea a great deal, but with the exception
of one or two vomiting spells, the first and second day, the nausea
did not often cause retching. The mouth and lips were dry, tongue
coated, bad taste in mouth and breath very offensive.
The reason there had not been more vomiting in this case was because
there was diarrhea at first and not quite so much locked up fecal
matter as common. The bowels had been relieved of the usual
accumulation more than is common to the majority of such diseases
before the swelling and fixation had become established.
There is a small percentage of people who are not quite so irritable
as others; in these the contraction, constriction or fixation--the
embargo laid on these parts by nature in her conservative effort at
preventing movement--is not established quite so early, and the
efforts on the part of doctors to force a movement are more
successful in cleaning out a part of the accumulation; or there may
come a diarrhea from the putrefactive poisoning which is causing the
infection of the cecum or appendix and leading to abscess, and this
causes a partial cleaning out before fixation is established; in
these cases there is never so much vomiting nor nausea, neither do
they suffer so much pain for there is not the usual accumulation in
the alimentary canal to excite the peristaltic movement.
The history that the patient and his wife gave me from memory was
that the urine had been scant, and at times painful to pass. There
had been from the start severe pain in the lower bowels, but neither
the patient nor his wife could remember if there had been more pain
on right, lower frontal region than anywhere else; they both
declared that the pain was all through the bowels and that there was
much bearing down like unto the pain of a diarrhea.
Breathing was shallow, of course; it never is otherwise in severe
abdominal distention.
I scarcely touched the abdomen, for I knew I dare not press, in
percussing, enough to distinguish any sound except the tympanitic.
It has never been my custom to allow my curiosity to run away with
my judgment, and cause me to make needless examinations.
All examinations are needless when, it matters not what the
diagnosis can or must be, the treatment will be the same. All
possible bowel troubles which present the same general symptoms of
the disease I am here describing, must receive a like general
treatment. This being true, it matters not what the difference is,
there cannot be a variation requiring a bimanual examination to
differentiate it that will justify the risk. All examinations are
needless and criminal when there is a possibility of rupturing an
abscess. Especially is this true when it is a_ positive fact _that
all typhlitic and appendicular abscesses will open into the bowels
if allowed to do so.
In this ease I reasoned as follows: This must be a case of abscess,
for the signs of obstruction are not those of complete obstruction,
such as are seen in hernias, volvulus, constricting bands and many
other causes not necessary to mention. If there were complete
obstruction there would be increasing nausea and vomiting, ending in
collapse and death. This tympanites cannot be from peritonitis for
perforation would be necessary to cause it and nothing would stop
the progress after it had once started except to open the cavity
wash and drain. Hence this cannot be peritonitis, for there has been
no operation and the patient still lives. It can be distention from
the effects of morphine, but there must be more than morphine
paralysis, for there is a temperature of 102 degree to 103 degree
F., and there has been, so the wife says, a temperature of 104
degree F. The pulse rate being 130 does not indicate fever nor
exhaustion, and is not in keeping with the temperature nor physical
strength, hence the rapidity must be partly due to pressure on the
diaphragm from the gas distention and partly from the paralyzing
effect that opium has on the heart.
The professional reader will see that I have by my analysis
eliminated much of the formidableness that the physical appearance
gives to this case, but I would not have you believe that this man
was not a desperately sick man even if I have accounted for the
dangerous symptoms. The fact is, if the pronounced symptoms had been
what they appeared to be, the man would have been saved his trip to
me, for he would have been dead.
The farmer had learned from experience that the less he put in his
stomach the better he felt; hence, for a day or two before he left
his home to consult me, he had refused food and drugs and had taken
very little water.
After giving the sick man a rest in my office I had his wife take
him to the home of a friend with whom they had arranged to stay
while in the city. In a few hours I visited him and made the
following prescriptions and proscriptions: Positively no food, not
one teaspoonful of anything except water. An enema of half a gallon
of tepid water to be used once each day for the purpose of clearing
out the bowels below the constriction, and I advised against
violence--rough handling. A hot water jug to the feet, fee to the
abdomen, all the fresh air possible in his bedroom and absolute
quiet. If nauseated, enough water to control thirst was to be used
by enema; if the stomach was all right all the water desired by
mouth.
I called the second day; the patient had slept some--he thought
about three hours of broken rest--feeling fairly comfortable; pulse
120, temperature 101 degree F. at 9:00 a.m.; 102 degree F. at 5:00
p. m. Third day: Temperature 100 degree F. at 9:00 a. m.; 101 degree
F. at 5:00 p. m.; one-third of the tympanites gone; slept six hours;
hungry and demanding food. I said, "No, you get no food until the
bowels move." The ice was taken off the bowels; hot cloths were
substituted.
The fourth day the temperature in the morning was 100 degree F.; in
the afternoon 101 degree F., pulse 100; slept well, hungry, bowel
distention reduced fifty per cent. I touched him very lightly and
found enough to confirm my diagnosis of typhlitic abscess; this was
the first time I had felt that I was justified in attempting to
confirm my suspicions, and even this examination could not be called
a palpation, for I put no weight upon the abdomen. The patient was
very dissatisfied because I would not allow him food. I said, "No.
you can't eat until your bowels move." "How soon will they move!"
he asked in an irritating and ungracious manner, to which I replied,
"Your God only knows, and He won't tell."
Fifth day about the same, a little better; very ugly because I would
not allow him food. He said: "I don't believe there is anything the
matter with me; you are holding me down."
Sixth day about the same, feeling fine, sleeping fine and _starving
to death. _He made himself so unpleasant by his clamoring for food
that I permitted his wife to give him a half dozen Tokay grapes. He
had scarcely swallowed the sixth when he had all the pain he wanted.
His wife came to my office in great excitement: "Doctor, please come
at once to see my husband; he is much worse, he is in agony with his
bowels." My answer was: "Go back and renew your hot applications to
the bowels and tell your husband I permitted him to eat the grapes
because he had been so unkind and ungrateful for the comfort that
had been given him; tell him that I knew the grapes would give him
pain and that the pain will not wear off entirely for twelve hours,
and that I will not see him before tomorrow morning."
I called as I agreed to do the next day, the seventh day since the
case came under my management, and the fourteenth day from the
beginning of the disease. The sick man was out of humor. To my
question, "Would you like something to eat!" he drawled, "Na-a-aw! I
never intend to eat any more; but I would like to know when my
bowels are going to move." Of course I could not tell him any more
than I had told him before, namely, that under such circumstances
they usually require from fourteen to twenty-eight days.
From this time on every day was much the same; no elevation in
temperature, and the pulse ranged from eighty to occasionally one
hundred; no pain, sleep good, that is, as good as people generally
sleep who are on a continuous fast--under a continuous fast the
sleep is good but not heavy nor long at a time.
It is a fact that when these cases are properly handled they are not
sick after the first week; they do not look sick; they get to
thinking that it is folly to stay in bed and live without food, and
of course their neighbors know that there isn't anything the matter
with them; that the doctor is starving them to death. Quite a number
of my patients have brought themselves near death's door from
disobeying instructions and taking the advice of knowing neighbors.
They were persuaded to "eat"--"eat all you want, for the doctor
will not know it."
This is one disease that will give the disloyalty of the patient
away every time.
On the morning of the nineteenth day of his sickness, and the
twelfth day of my services, I called to see the sick man, and before
I could ask him a question he shot out his hand toward me and
exclaimed, "My bowels moved at four o'clock this morning! I want a
beefsteak for my breakfast!" I congratulated him on his fine
condition and ordered him a dish of mutton broth. This disgusted him
thoroughly, and his reply was in kind: "A dish of broth! After
fasting two days on my own prescription, and then twelve days on
yours, I am to be rewarded with a dish of broth." I explained that
he had a large abscess cavity that would require several days to
empty, collapse and draw together, and if he should eat solid foods
too soon he would run the risk of cultivating chronic
appendicitis--recurring appendicitis. I advised him to live on
liquid foods for three or four days, and after that he could have
solid foods if he would practice thorough mastication.
The action from the bowels had been saved for me; there was an
ordinary chamber half full; it looked to me like at least a half
gallon of fecal matter, pus and blood; it was dreadfully offensive.
Six hours after the first movement I was informed that he had
another movement very similar in quantity and consistency; this
movement I did not see, for I did not visit the man after the
morning of the nineteenth. He left for his home on the morning of
the twenty-third and has had excellent health ever since.
If this man had been subjected to daily examinations food and drugs,
would he have presented the same symptoms! Indeed the tympanites
alone would have killed him. Was his case _diffuse peritonitis? _No!
For if there had been intra-peritoneal infection in the first place,
it would have indicated perforation, and then, without the opening
up of the peritoneal cavity, washing and draining, there would have
been a funeral.
The following is a similar case except that the woman came into my
hands the first day of her sickness. Her symptoms were: Nausea,
vomiting and pain all over the bowels as she said--as much pain in
one place as another--temperature 102 degree F., which ran up to 103
degree F. in the p. m.; pulse 110, and a history of constipation.
She had several movements from the bowels through the night before I
was called in the morning. The movements were small and accompanied
with much griping; the patient said that if she could have a good
cleaning out of the bowels she felt that she would be well. I
informed her that she had appendicitis and that she would be
compelled to remain very quiet in bed, with ice applied locally
until the temperature was reduced to 101 degree F., or less, and
then substitute hot applications. For the pain I had her stay in the
hot bath until relieved, and when the pain returned she was to go to
the bath again. The bath water was ordered to be used as hot as
possible. Every night an enema of warm water. The treatment did not
vary from the farmer's and the results were the same--her bowels
moved on the nineteenth day; the consistency and amount were about
the same, and I had her exercise care about her eating for a week
after the abscess discharged. From the end of the first week of her
sickness until the abscess broke she expressed herself freely that
she did not believe there was anything the matter, and that going
without food when one felt well was foolish; however, she obeyed and
had no suffering.
A son of the woman whose case I have reported above was taken down
the same way one year after. I explained the situation and told the
young man that he must keep quiet and go without food just as his
mother did the year before. I did not think it necessary to visit
him very often, for he knew how his mother was treated, besides she
was with him to advise.
Within three days he was comfortable, and remained so until about
the seventh or eighth day, when he decided he would take a glass of
milk and not say anything to me about it. He took the milk and was
writhing in pain within two hours. I was sent for, and of course
asked what he had eaten, whereupon he told me that he had taken
milk. Within twenty-four hours he was easy and cured of his desire
to eat until ready for it. This case terminated by rupture of the
abscess on the fifteenth day.
Neither of these cases had any tympanites worth mentioning. All
cases that I have ever seen with great bowel distention are those
coming into my care after being subjected to the usual feeding and
medicating.
Now we will go over Dr. Vierordt's case in connection with mine and
see if his case of diffuse peritonitis is not about as near like my
case as it is possible to have two cases.
His patient was a merchant 31 years old, mine a farmer 42 years old.
There is a difference in these two men, caused by their occupations.
The merchant could not have made the trip to my office as did the
farmer, for several reasons: First, merchants are pampered; they are
not used to discomfort; they are not used to waiting upon themselves
as country men are. When they are sick they send for the doctor; the
farmer goes to the doctor. The merchant has learned the habit of
spending his money and the farmer has learned the habit of saving
his, and perhaps that one statement is enough for the discerning.
The merchant was too sick to make such a trip and he knew it. The
farmer was too sick to make the trip and he didn't know it. This is
the vital difference between these two cases.
The merchant was tympanitic from the first day of his prostration,
which is not usual. On the fourth day his temperature was 104 degree
F., pulse 120 to 136, mind clear but anxious. His lesser symptoms
were about like the farmer's, with the exception that the merchant
had been given more narcotics and presented more of the dorsal
decubitus than the farmer. Laymen, the plain everyday meaning of
dorsal decubitus is lying on the back. In low forms of disease it is
looked upon as an unfavorable symptom. Where much morphine has been
given it denotes prostration peculiar to the drug. My patient was on
his back for several days, because it is impossible for a patient to
stay on either side while suffering from severe tympanites.
On the sixth day the merchant's pulse was 140 and the temperature
101.3 degree F., which proves, if nothing else does, that he did not
have diffuse peritonitis, for it is impossible for a patient to have
_acute, diffuse peritonitis, _be drugged and fed, and go through the
daily physical examinations such as he was put through, and on the
day before the abscess breaks into the bowels show a temperature of
101.3 degree F. The pulse counts for nothing in such a case as this;
I did not look upon the farmer's pulse as indicative of any serious
state, for I knew the opium had caused it. If the pulse of either
the merchant or the farmer had been due to peritonitis death would
have ended either one before his abscess had broken. In fact diffuse
peritonitis comes from perforation with discharge of the abscess
contents into the peritoneal cavity, and it always spells death.
When vomiting recurs, or continues after the third day, there is
malpractice, or there is a serious complication, or there is a
mistaken diagnosis.
It is well to get this one fact well in mind, namely, appendicular
and typhlitic abscesses are not accompanied with complete
obstruction; hence, when the symptoms are so profound as to point to
absolute obstruction, no delay should be made in having the abdomen
opened and the obstruction, whatever it is, should be removed at
once.
The fact that the bowels do not move in from twelve to twenty-one
days should not be looked upon as total obstruction. What
obstruction there is is due to fixation of the parts and is truly a
physiological rest--it is on the order of the fixation of an
inflamed joint--the joint appears to be anchylosed, but as soon as
the pain is gone it becomes as movable as ever.
Again, if the case is really obstruction it will grow worse daily
even if my plan of treatment--absolute rest from everything--is
carried out to the letter.
There is not any danger of the abscess opening anywhere except into
the bowels, for that is in the line of least resistance and, if it
fails to do so, it is because it is badly managed.
CHAPTER IX
_I have appendicitis; what shall I do to be saved? _Don't eat
anything until well. Use a stomach tube and wash out the stomach;
then use a fountain syringe and wash out the bowels; take a hot bath
as hot as can be borne, and stay in the tub until all the pain is
gone, or as long as possible; then go to bed, put ice on the bowels
and keep it on until the temperature is reduced to 101 degree F.,
then apply hot applications or poultices and continue the poulticing
until the bowels move, and the bowels will not move until the
abscess breaks.
Use an enema every night as a routine, and drink all the water
desired, when there is no nausea.
Don't manipulate the forming abscess, nor allow anyone else to do
so.
If you are really in doubt about what you have, think over what I
have written about strangulation or positive obstruction, and if you
think you have it, send for the best physician you know and get his
opinion of whether you have obstruction or not, but don't allow him
to burst an abscess with his manipulations! For, my word for it, if
he can't weigh symptoms and tell whether or not you have complete
obstruction without punching holes in you with his bimanual
manipulation, neither would he be able to do so after examining you.
I do not say this because I like to make it hard for doctors, but I
prefer staying the heavy hand of the doctor to keeping still and
allowing him unwittingly to kill his patient.
First of all wash the stomach out with a siphon tube, then see to it
that nothing but water goes into the stomach until the bowels move.
I put my cases on a complete fast, give no drugs, apply ice to the
region of the appendix, keep the feet warm, and keep the patient in
an atmosphere of hope and belief in his recovery, and a recovery
always follows. I prescribe an enema of warm water once or twice
daily, getting all the water possible into the bowels.
These patients are so comfortable after the second or third day that
it is hard to make them or their friends believe that they have
appendicitis People are so afraid that they will starve to death if
they have no food for a few days that they make haste to get put on
a killing treatment rather than run any risk. This fear is absurd
Physicians are largely to blame for this popular ear, for those who
do not feed by mouth still have the idea that their patients must
have nourishment, so they feed by rectum. This is also absurd. What
the patient needs is rest, and the more complete the rest the
quicker the recovery. Give the patient all the water he wants.
The bowels will move in fourteen to twenty eight days from the
beginning of the attack. Then the fast can be broken by giving a
glass of hot milk, which is to be chewed well, or given in the form
of junket; this is to be repeated three times a day for a week, or
give the milk twice a day and a plate of mutton broth for the third
meal. I do not give solid food because there is a large abscess
cavity opening into the bowels, and if solid food is given before it
has time to close, it is liable to find its way into this cavity,
thereby preventing healing, and bringing on a chronic condition that
will ultimately end in death. The less food taken for one week after
the discharge takes place, the better. Any rational individual
should see that withholding food is the proper treatment. Milk
should be thoroughly mixed with saliva or not taken at all. Remember
that if milk is not taken with great deliberation, and great care
given to _thoroughly insalivate each sip, then it amounts to the
same thing as eating solid food._
Milk is a solid food when taken into the stomach as a beverage or a
drink like water.
In appendicitis all nature cries out for rest, and if it is given 99
out of every 100 cases will get well and there will be no suffering
and no danger after the first seventy-two hours.
The ordinary physician sends for a surgeon, and if he is a victim of
the surgical mania the patient must be operated upon at once, for if
twelve or twenty-four hours are given, the conditions may clear up
and an operation will be unnecessary. The majority of surgeons feel
that they will forfeit their right to heaven if they do not cut at
once. The consequence is that there are many patients operated upon
who are as innocent of having the disease as the surgeon is innocent
of a knowledge of a better plan of treatment.
Of course, the surgeon declares that pus should be let out by
cutting into it, or it is liable to break into the peritoneal cavity
and cause death This is positively not the truth, for when an
abscess threatens, nature at once proceeds to throw a wall around in
order to avoid accidents. All around the point of prospective
abscesses, heavy walls of adhesions are built, and if nature is not
interfered with, the abscess will break into the gut, because it is
the point of least resistance, and it is also the point favored by
gravity. The surgeons when they operate in these cases work exactly
opposite to nature.
If these abscesses are allowed to open into the bowel and solid food
is kept away from the patient, full and uncomplicated recovery will
take place. If solid food is given too soon it is liable to find its
way into the abscess cavity and cause a blind fistula, which may
take on acute inflammation at any time. These cases then become
chronic and are called recurring appendicitis. It is sound surgery,
in dealing with abscesses, to find, if possible, the direction
nature is taking to evacuate pus and be guided by this suggestion in
evacuating a pus cavity.
In order to cure appendicitis you must remove the cause. Cutting off
the appendix, opening an abscess, withholding food till the acute
symptoms have passed; such treatment is not removing the cause.
Nothing short of changing the eating habits of the patient will
cure, so the surgeon who knows nothing about food and its
action--what part improper eating has to do with bringing on the
disease--will never be able to cure.
Operating for this disease will fall into disrepute in time, for
there are already cases recurring and the second and third operation
will be necessary among those who survived the first. There is not a
scintilla of logical reasoning in defense of the operation. Because
some get well after an operation is no proof that the operation was
necessary; fortunately for the operator there is no way to prove
that the case operated upon would have recovered without the
operation. If the case be not complicated by bungling treatment an
operation is uncalled for. If a case has been medicated and fed to
death--abused to the extent of causing a rupture into the peritoneal
cavity--surgery must be resorted to as the only hope.
If a case survive an operation the patient is no wiser than he was
before, and knows nothing about avoiding another attack, for let it
be said loud enough to be heard by all, and with no fear of
successful contradiction, that if every child at birth should have
the appendix removed there would not be one case less of
appendicitis than there is with the appendix intact. Of course,
technically there could be no appendicitis without an appendix, but
the cecum would become inflamed just as readily.
No amount of forcing drugs given by the mouth can induce a movement
from above the constriction, but a great amount of pain can be
produced by attempting to force a passage. No one comprehending the
true state of affairs would be foolhardy enough to try to force the
bowels to move. The reader can readily imagine the great pain and
danger liable to follow cathartic drugs, for they stimulate severe
peristaltic contractions. The contractions drive the contents of the
small intestine against the inflamed cut-off, but there it must
stop. If the parts have become softened, which they do by the
inflammation, there is danger of perforation and an escape of the
contents of the bowels into the peritoneal cavity, after which
diffuse peritonitis and death follow. Surgery can hardly hope to
save such patients; in fact they usually die; this is why the
surgeon recommends an early operation.
If all cases are to be so abused and if there were no better way to
treat them I also should say, operate at once as soon as the disease
is discovered; but I know from years of experience that there is a
better way to care for these patients.
CHAPTER X
Allow me to repeat: As soon as a case is diagnosed the proper
treatment is to stop all medicine and food, for they excite
movement, and this should be avoided. Give nothing but water. Keep
ice over the inflamed spot. Keep the patient quiet, end the feet
warm. There is absolutely nothing to be done until the bowels move,
which will take place in from fourteen to twenty-eight days. The
patient will not starve to death, nor will there be any danger that
the abscess will open anywhere except into the bowels. After the
bowels move, one glass of hot milk is to be given three times a day,
so there will be no danger of solid food finding its way into the
cavity of the abscess.
To be safe I insist on a fluid diet for a week after the bowels
move, and a light diet for two or three weeks more. Cases taken
through in this way, and then instructed in never allowing the
bowels to become loaded again, will not only make a good recovery,
but there is no tendency for the disease to return if the patient is
prudent. I say that there need not be a death from this disease if
these suggestions are properly carried out. The cases that die every
year are killed by food and medicine.
Surgery has gained its reputation in these cases because of the
stupidity of the average physician and patient. Cases taken through
in this way are comparatively comfortable; they may pretend to
suffer from hunger, but it is principally imagination. If my plan
were generally adopted the dread of this disease would disappear;
surgeons would get left on some fat fees, and the undertaker would
look glum after the fall crop.
There are a few laymen so willful and incorrigible that they can't
be depended upon to follow instructions. They will break rules, be
imprudent in eating, and in many ways disregard their own interests.
Such cases should be sent to the surgeons as early as possible,
before they have time to complicate their disease and make a
complete recovery impossible; however, people with such temperaments
usually find an early grave and they might as well go by the
surgical route as any other.
End of The Project Gutenberg Etext of Appendicitis: The Etiology, Hygenic and Dietetic Treatment
by John H. Tilden, M.D.
