Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 2

"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 const.i.tutional 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 a.s.sertion 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 c.o.c.ksure 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 cla.s.s 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 ent.i.tled 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 circ.u.mscribed 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 cec.u.m 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 cec.u.m 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 quant.i.ty 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 cla.s.s 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 cec.u.m 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 a.s.sume an att.i.tude 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 cec.u.m.

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 cec.u.m, 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 cec.u.m. These muscles are contracted to such an extent that the right thigh is often drawn up in order to relieve the tension.

When the cec.u.m is inflamed it is common for the colon to be loaded; this colon obstruction prevents the onward pa.s.sage 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.