Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 4

[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 subst.i.tuted. Vomiting was rare, was invariably bilious and coa.r.s.e-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 circ.u.mscribed 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; circ.u.mscribed 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 a.n.a.lysis were lacking.]

"The diaphragm was raised; except for a small zone liver dullness was absent."

[Of what possible benefit was this knowledge under the circ.u.mstances?]

"Now and then there was gra.s.s-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 circ.u.mscribed 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 circ.u.mscribed perityphlitic abscess." How was it possible with meteorism as described, to say that there was a sharply circ.u.mscribed perityphlitic abscess? It was tacitly a.s.suming 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 cec.u.m, 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 circ.u.mstances 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 pa.s.sing 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."_