Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 3

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, was.h.i.+ng 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 cla.s.s 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 circ.u.mstances, 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 cla.s.s 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 r.e.c.t.u.m.]

"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 quant.i.ty 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 Circ.u.mscribed 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 r.e.c.t.u.m in the dorsal decubitus, nothing abnormal was noted except pain in the floor of the pelvis; the r.e.c.t.u.m was empty.

"Since morning neither feces nor flatue had been pa.s.sed; 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 alb.u.min 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 rec.u.mbent posture; that, for the present, only small quant.i.ties of ice be taken by the mouth;"