Appendicitis: The Etiology, Hygenic and Dietetic Treatment
by
John H. Tilden, M.D.
Part 1 out of 2
Created by Steve Solomon (ssolomon@soilandhealth.com)
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
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