Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 6

In proper hands this young man would not have been very sick; possibly his trouble would have been thrown off and the inflammation pa.s.sed off by resolution.

The following should be of interest for it is a very _scientific explanation _of how the young man came to die:]

"The clinical history is in every respect typical and instructive.

"It shows us that the origin of peritonitis which is by far the most common, is in a diseased appendix. At the autopsy this was found necrotic and perforated. It is questionable whether the perforation existed from the onset of the disease; it is possible that at first an ulcer extending to the serosa caused an infection of the peritoneum; at all events this occurred acutely, and produced the sharply defined disease."

[I agree. The perforation brought on the relapse and the collapse.]

"The clinical abdominal symptoms in the first period of the malady pointed to the fact that at the onset there had been a diffuse inflammation of the peritoneum, and that later, by the adhesions to the appendix which were found at the autopsy an early encapsulation of pus had taken place in the ileo-cecal region; this produced a purulent softening in the wall of the cec.u.m and led to the favorable rupture of pus into the intestine and to an immediate amelioration of the acute peritonitis. The point of rupture, however, then closed, and partly perhaps to the action of fresh infectious and toxic material, perhaps only to the perforation of the appendix, may be ascribed the exacerbation of the peritonitis, that is, a renewed attack which caused the death of the patient."

[The symptoms were those of intestinal putrefaction with local inflammation of the cec.u.m and, as the history of the ease has pointed out, was located in that part of the cec.u.m giving attachment to the appendix, for the autopsy showed that the appendix was surrounded by adhesions and imbedded in fecal pus. Please note particularly: The appendix was found in a pus cavity--a perityphlitic abscess. Why shouldn't the appendix be necrosed?

Located in a field of inflammation, blown up, distended beyond its vital integrity; why should it not become gangrenous, It doesn't matter when the perforation of the appendix took place for it is quite evident that there was not enough disease of the appendix to cause its perforation until after it had become encased in the abscess cavity, and if the young man could have been freed from the treatment he received and could have been given the necessary rest the abscess cavity would have emptied itself, necrosed appendix and all, into the bowel and he would have made a perfect recovery.

"The point of rupture closed!" How could a rupture into a distended gut close, The distention was greater after the rupture than before.

Fresh infection could not take place without a power to force the putrefaction greater than the force that existed before the abscess broke into the cec.u.m. Let us reason together: Nature fought successfully against heavy odds before the rupture. There was gas distention of bowels interfering by pressure with the circulation and increasing the area of destruction of tissue; frequent retching and vomiting interfering by stretching and probably tearing, threatening disruption to the plastic process that was going on to close in the disorganizing and necrosing processes; the frequent examinations, and manipulations for diagnostic purposes, etc., but, in spite of all this opposition, fatal infection was successfully resisted; then, after the rupture and discharge, the relaxation, the calling off by nature of all her defenses, showed that the battle was won. All the defense yet left was the hard induration, "firm, flat resistance." This induration was quite sufficient to prevent reinfection, had there not been something out of the regular order to interfere. In this case there was a prostrated muscular system.

The narcotic had left the patient without muscular power. The starchy food created gas, and the bowels, not having their natural tone, gave way to the gas until there was _"Meteorism,"_ not tympanites but meteorism which means to blow up or distend all that is possible.

Such a state as that means mechanical interference with every organ in the thoracic, abdominal and pelvic cavities, and, besides the pressure and interference in drainage and the blowing into the abscess cavity and into the pyogenic membrane gas loaded with infection, there was an almost fatal interference with the action of the heart and lungs. The prostrating effect on the muscular system of the septic or putrefactive poison was nothing to be compared to the paralyzing effect of opium. I believe this man would have survived every interference if the milk gruel had been left out, but acting as it did, it proved to be the last straw.]

"In regard to the fulminant symptoms at the onset of the disease, however, it is more likely that even then perforation had already occurred, and I that the final and fatal exacerbation was in consequence of adhesions formed in the first period which were powerless to resist the entrance of organisms producing inflammation. The pus finally broke through the adhesions, and produced diffuse peritonitis."

[It is a technical point unnecessary to raise whether the adhesions formed in the first or the last period; they were formed without question; I and if they were formed in the beginning, as doubtless they were, they withstood the most severe and trying period of their existence, which was before the abscess broke into the bowels, and so far as being able to resist to the very last, there has been no evidence to prove that the last infection was because of any lack of power of resistance on their part for the autopsy showed them intact. It is doubtful if anything but sound tissue could have withstood the strain that was put upon this man's diseased cec.u.m from gas distention. The infection-laden gas could find a way anywhere in diseased tissue and broken continuity. Why should the pus break through the adhesions and find its way into the peritoneum after they had been able to make an effectual resistance till the bulk of it had forced a pa.s.sage into the bowel? Why should the adhesions have less power to resist when there is less strain upon them and also a patent outlet for the pus? I fear our German friend of "Die Deutsche Klinik" had "booze" in his logic when he was explaining how his patient came to die.]

"Moreover, the bacterial finding of streptococci and cold bacilli in the perityphlitic abscess is typical, and the limitation of the diffuse peritonitis to areas below the omentum is also instructive.

This simultaneously prevented the invasion of organisms producing inflammation into the serous surfaces above."

[There is nothing strange about this for nature works for the purpose of preventing "serous surface" invasion, and it takes a deal of malpractice to force such an infection. If nature's provisions against peritoneal inflammation were not as great as they are, few people with intestinal putrefactive diseases, from cholera infantum in babyhood to proct.i.tis in old age, would get well, for most of the treatment for one and all of these diseases is obstructive rather than conservative and helpful.]

"This strong man, aged 31, had previously regarded himself as perfectly well. Nothing indicated the danger in which he found himself and which had existed since the appearance of the fecal calculus. the time when this had formed being impossible to determine. The disease appeared acutely with fulminant symptoms."

[He was, indeed, unfortunate, but his greatest misfortune, as I see it, was his treatment. Every acute disease is fulminant, even indigestion is fulminant, but the force of the warring elements is soon expended and unless reinforced by fresh elements the fulmination must end.

In diseases such as typhoid fever, appendicitis and typhlitis, we have first of all a const.i.tutional derangement brought on by errors of life. The general resistance is lowered from nerve-exhausting habits; the general tone of digestion is below par and the bowel contents are maintaining a higher toxic state than usual; we have added to this condition an unusual tax in a long run of hot weather, business worries or unusual mental, physical or digestive strain, following which acute intestinal indigestion manifests with a sudden explosion; or there takes place a transformation of the contents of the bowels into an intense putrefaction which infects a portion of the mucosa that has been rendered susceptible by pressure from fecal impaction, concretions, or any cause capable of devitalizing. If the infection takes place in Peyer's patches, typhoid fever is the consequence; if the local trouble is of the cec.u.m, typhlitis will result, and if the local devitalization is in the appendix, brought on from the irritating effects of a fecal calculus, appendicitis will result.

These diseases may start in a fulminant manner as suggested--with an acute intestinal indigestion, which will die down as soon as all the elements that combine to set off this fulmination l eve expended their force and unless fresh material be added everything must settle down to a local trouble. Or if the primary irritation is subjected to a light form of toxic infection the development of the disease will be much more insidious and will require much more time to come to its maturity, or its fulminating stage.

The reason for this is that each person has a cultivated immunity to a given toxic state of the intestinal contents, and when from pressure or the irritation caused by a calculus. there is a denudation of the mucosa the infection that takes place has not the power to arouse a systemic resistance' but can cause only a local inflammation; this inflammation may end in ulceration, or it may cause a thickening of the parts and interfere with drainage from mucous or glandular pockets; then the locked up secretions become intensely toxic, and this sets up a new infection much greater then l the first and powerful enough to cause the system to call out its militia to put down the rebellion. Now we have fulmination, but if food and drugs are withheld it ends soon.]

"Severe abdominal pain with tense abdominal walls, fever and vomiting form the characteristic triad in the first phase of the disease; less rapidly does meteorism appear. This depends upon whether the inflammation of the serosa quickly spreads or remains local. Peritoneal meteorism is peculiar. The abdomen is uniformly distended, balloon-like; the muscles as well as the rest of the abdominal walls are tense. It must be added, how ever, that in spite of the excruciating pain upon touch there is no sign of contraction of the abdominal muscles, of the "muscular resistance" _(defense musculaire) _which is so common on pressure in other forms of abdominal pain, particularly when circ.u.mscribed."

[Distention from any cause--or stretching of muscular fiber--causes paralysis for the time being.]

"The same is true of the diaphragm; it is forced upward, the muscles are therefore elongated and tense; but there is no evidence of active contractions. Abdominal respiration ceases; gradually then, as may be recognized by the limits of percussion, increasing loss of _muscle tonus_ is added. In this case the autopsy showed that the peritonitis had not advanced up to the serosa of the diaphragm."

[The muscle tonus when a patient is under the influence of opiates cannot be reckoned with, for that drug paralyzes the muscles, and the bowels fill with gas as was seen in this case up to the day before the abscess ruptured; on that day feeding had been suspended, resulting in a decrease of gas and an amelioration of all the symptoms.]

"Among these signs pain, either spontaneous or upon touch, a rise in temperature, increased frequency of the pulse and, in general, the signs of severe illness, are to be looked upon as the local and general symptoms of a severe septic inflammation; vomiting, at least in the first stages of peritonitis, was due to decided reflex irritation of the numerous branches of the peritoneal nerves; the fecal discharges at the onset may be explained, but by no means invariably, as due to peristalsis acting reflexively. The constipation which followed this, however, as well as the meteorism, must be attributed to a hypotonia and paralysis of the musculature of the intestine by collateral edema."

[Beautiful sophistry. Words well woven together are captivating and frequently dethrone reason. If I didn't happen to know better I might really believe the author of this contribution to medical science knew exactly what he was talking about.

The constipation in such diseases as this is caused by the fixing, or natural resistance to motion, which is always to be found in diseases of tile bowels and is one of nature's conservative measures. The hypotonia or paralysis of the musculature was brought about by the opium; and it is certainly strange that educated men can build a symptom or condition by the administration of drugs and yet remain absolutely unconscious of the part they are playing, and proceed to build a beautiful theory explanatory of results.]

"The excessive abdominal pain, increased by movement and on the slightest pressure, caused the patient to remain motionless upon his back and to avoid the slightest movement of the abdomen either by speaking or coughing."

[This is a characteristic symptom when there is great distention of the bowels.]

"At the start the temperature was uniformly high, but later remissions in the pus fever were recognized."

[All fever would have disappeared had it not been that the intestinal putrefaction was kept alive by feeding.]

"The pulse from the onset was comparatively frequent, regular and somewhat tense.

"The vomitus was at first composed of the gastric contents, the bile of a peculiarly pure, gra.s.s-green, biliverdin color mixed with a yellowish chyme-like material, and in the later stages of the disease showed thin ma.s.ses having a fecal odor_ (ileus paralyticus)._ In regard to the dejecta, the two pa.s.sages at the onset of the disease pointed to increased peristalsis; this was of short duration, soon changing to the opposite condition, and until the rupture of the perityphlitic abscess absolute constipation existed."

[The vomiting would have gone to stay within three days if no drugs nor food had been given; as it was, when real vomiting ceased the opium nausea began.

This patient was not allowed to come into that state of peristaltic elimination that is due in all cases in three days at the farthest, and which would have come to this man if food and drugs had been withheld.]

"Pain upon urination and strangury was due to inflammation of the peritoneal coat of the bladder, in which a noticeable irritation was produced by slight distention as well as by contraction of the bladder. The alb.u.minuria was the well known infectio-toxic 'febrile'

form; indicanuria was in proportion to tile fecal stasis.

"In the course of the next few days a new symptom was added to this group: Exudation, which was demonstrable both by palpation and percussion. It was the natural consequence of inflammation of the peritoneum, and was both of diagnostic value as indicating general peritonitis and of special value in that, more definitely than the pain, it pointed to the original seat of the affection, which, according to present indications, could only have been an internal incarceration following right-sided inguinal hernia, or femoral hernia, or appendicitis. As neither the history nor the general status (normal condition of the hernial rings) furnished any points of support for the first view, only the diagnosis of appendicitis, that is, of perforation of the appendix, could be made with that degree of certainty attainable in diseases of the abdominal cavity in general.

"After the appearance of these symptoms, a more or less firmly adherent but limited perityphlitic abscess, and a less intense although well developed peritonitis in this region, were a.s.sumed; the latter, notwithstanding the painful meteorism, was not necessarily diffuse in the strict sense of the term; the omentum often protects the upper abdominal cavity from infection, as was proven in this case at the autopsy. It is possible that this diffuse peritonitis, which did not in the early period of the affection extend beyond the limited local focus, was not due to the intestinal contents and to bacteria, but chiefly to bacterial toxins which arose from the circ.u.mscribed original focus. This fact is pointed out by the prompt retrogression of the diffuse peritoneal symptoms after rupture of the abscess; the diffuse peritonitis of this stage might then be designated a nonbacterial 'chemical' inflammation, according to the terminology now in vogue; finally, it was positively a bacterial infection, although the postmortem finding of bacteria in the distant folds of the peritoneum is not proof of this; we know that during the terminal agony or after death these may wander a long distance from the perityphlitic focus."

[The author plays so fast and loose with the words, "diffuse peritonitis," that I am reminded of a remark made to me several years ago by a society lady who posed as a pace-setter in all matters pertaining to the intricacies of what one should and should not do. The subject was one that I did not know much about at that time, and upon which I am not much better informed at present. It was on diamonds. I complimented her on a very beautiful sunburst.

She took the compliment modestly, of course. The center diamond was large and, I thought, of uncommon brilliancy, and I remarked, "That center stone properly mounted would make a very fine solitaire." She then informed me that she once owned a _cl.u.s.ter of solitares._

The author tells us that at first the diffuse peritonitis probably did not extend beyond the local focus; this of course is exactly what I am contending for from first to last and I insist that there was not peritonitis proper until the occurrence of the fatal relapse.

It is somewhat surprising that this article should be selected to represent the last word on this subject, when the author builds his treatment upon diffuse peritonitis; then enters into a lengthy a.n.a.lysis and explanation of symptoms to fit the diagnosis and treatment and before he is through with the subject he declares that the _diffusion is confined _to the focus of infection.

If I did not know something of the worth of words I am not sure but such an excellent explanation might persuade me!! If I did not know from experience that all this is _theory, beautiful theory, _it might be very hard to resist!]

"After the symptoms of local and general inflammation with their secondary signs in the stomach and intestine had lasted for six days, suddenly a complete change took place: The nervous, anxious, extremely distressed patient became feeble and scarcely complained at all; his formerly congested face was pale and elongated, the nose pointed and cool; the skin lost its turgescence and warmth and was covered with a cold sweat; the bodily temperature also fell, the pulse became small and frequent but remained quite regular, the abdomen became softer and to a great extent lost its sensitiveness; the vomiting decreased to a few painless attacks,"

[Wholly due to the opium and morphine given]

"and singultus disappeared: A picture which, to a certain extent, is a combination of collapse and narcosis although not to the degree of profound loss of consciousness, being the picture of an intoxication in sharp contrast to the preceding febrile state."

[That is exactly what I stated above--a case of narcotism. How is it possible that the author, recognizing the narcotism, feels it inc.u.mbent to give other explanations?]

"Just as the affection had suddenly developed to its full height at the onset of the disease, and much more swiftly than, for example, is the case in phlegmon of the external walls, so with extraordinary rapidity did the clinical picture a.s.sume a new type. In this respect we must consider the very great area of the peritoneal folds, their numerous lymphstomata, and their intimate relation to the circulation, and we are impressed with the fact that fluids and solubles, as well as formed products, are rapidly absorbed by the peritoneum.

"Somewhat less rapidly than this, but nevertheless in the course of a few hours, another change took place, a favorable turn following the rupture of pus into the intestine. Here we were dealing with a well known and familiar phenomenon; if this occurs in the peritoneum the effects are particularly well marked; similarly as in the case of a phlegmon which rapidly disappears with the discharge of pus even although the inflammation extend beyond the pus focus, the symptoms of diffuse peritonitis promptly disappeared after the rupture. Very likely, as has already been stated, the symptoms of diffuse peritonitis in the first stages of the disease are to be referred to a chemical inflammation of the serosa, i. e., one due to toxins and without the ingress of bacteria; and it must be remembered that the clinical picture of this chemical peritonitis cannot be differentiated from that of the severe bacterial form.

With the rupture of the abscess, the entrance of poisons into the free peritoneal cavity, and their resorption by the extensive peritoneal surfaces, as well as the vomiting and the intestinal paralysis, ceased. The taking of nourishment again be came possible.

"The point of rupture formed adhesions, the natural drainage of the peritoneal ichorous focus ceased, perhaps a new influx of inflammatory material from the perforated appendix also took; place.