Appendicitis: The Etiology, Hygenic and Dietetic Treatment Part 8

This is one disease that will give the disloyalty of the patient away every time.

On the morning of the nineteenth day of his sickness, and the twelfth day of my services, I called to see the sick man, and before I could ask him a question he shot out his hand toward me and exclaimed, "My bowels moved at four o'clock this morning! I want a beefsteak for my breakfast!" I congratulated him on his fine condition and ordered him a dish of mutton broth. This disgusted him thoroughly, and his reply was in kind: "A dish of broth! After fasting two days on my own prescription, and then twelve days on yours, I am to be rewarded with a dish of broth." I explained that he had a large abscess cavity that would require several days to empty, collapse and draw together, and if he should eat solid foods too soon he would run the risk of cultivating chronic appendicitis--recurring appendicitis. I advised him to live on liquid foods for three or four days, and after that he could have solid foods if he would practice thorough mastication.

The action from the bowels had been saved for me; there was an ordinary chamber half full; it looked to me like at least a half gallon of fecal matter, pus and blood; it was dreadfully offensive.

Six hours after the first movement I was informed that he had another movement very similar in quant.i.ty and consistency; this movement I did not see, for I did not visit the man after the morning of the nineteenth. He left for his home on the morning of the twenty-third and has had excellent health ever since.

If this man had been subjected to daily examinations food and drugs, would he have presented the same symptoms! Indeed the tympanites alone would have killed him. Was his case _diffuse peritonitis? _No!

For if there had been intra-peritoneal infection in the first place, it would have indicated perforation, and then, without the opening up of the peritoneal cavity, was.h.i.+ng and draining, there would have been a funeral.

The following is a similar case except that the woman came into my hands the first day of her sickness. Her symptoms were: Nausea, vomiting and pain all over the bowels as she said--as much pain in one place as another--temperature 102 degree F., which ran up to 103 degree F. in the p. m.; pulse 110, and a history of constipation.

She had several movements from the bowels through the night before I was called in the morning. The movements were small and accompanied with much griping; the patient said that if she could have a good cleaning out of the bowels she felt that she would be well. I informed her that she had appendicitis and that she would be compelled to remain very quiet in bed, with ice applied locally until the temperature was reduced to 101 degree F., or less, and then subst.i.tute hot applications. For the pain I had her stay in the hot bath until relieved, and when the pain returned she was to go to the bath again. The bath water was ordered to be used as hot as possible. Every night an enema of warm water. The treatment did not vary from the farmer's and the results were the same--her bowels moved on the nineteenth day; the consistency and amount were about the same, and I had her exercise care about her eating for a week after the abscess discharged. From the end of the first week of her sickness until the abscess broke she expressed herself freely that she did not believe there was anything the matter, and that going without food when one felt well was foolish; however, she obeyed and had no suffering.

A son of the woman whose case I have reported above was taken down the same way one year after. I explained the situation and told the young man that he must keep quiet and go without food just as his mother did the year before. I did not think it necessary to visit him very often, for he knew how his mother was treated, besides she was with him to advise.

Within three days he was comfortable, and remained so until about the seventh or eighth day, when he decided he would take a gla.s.s of milk and not say anything to me about it. He took the milk and was writhing in pain within two hours. I was sent for, and of course asked what he had eaten, whereupon he told me that he had taken milk. Within twenty-four hours he was easy and cured of his desire to eat until ready for it. This case terminated by rupture of the abscess on the fifteenth day.

Neither of these cases had any tympanites worth mentioning. All cases that I have ever seen with great bowel distention are those coming into my care after being subjected to the usual feeding and medicating.

Now we will go over Dr. Vierordt's case in connection with mine and see if his case of diffuse peritonitis is not about as near like my case as it is possible to have two cases.

His patient was a merchant 31 years old, mine a farmer 42 years old.

There is a difference in these two men, caused by their occupations.

The merchant could not have made the trip to my office as did the farmer, for several reasons: First, merchants are pampered; they are not used to discomfort; they are not used to waiting upon themselves as country men are. When they are sick they send for the doctor; the farmer goes to the doctor. The merchant has learned the habit of spending his money and the farmer has learned the habit of saving his, and perhaps that one statement is enough for the discerning.

The merchant was too sick to make such a trip and he knew it. The farmer was too sick to make the trip and he didn't know it. This is the vital difference between these two cases.

The merchant was tympanitic from the first day of his prostration, which is not usual. On the fourth day his temperature was 104 degree F., pulse 120 to 136, mind clear but anxious. His lesser symptoms were about like the farmer's, with the exception that the merchant had been given more narcotics and presented more of the dorsal decubitus than the farmer. Laymen, the plain everyday meaning of dorsal decubitus is lying on the back. In low forms of disease it is looked upon as an unfavorable symptom. Where much morphine has been given it denotes prostration peculiar to the drug. My patient was on his back for several days, because it is impossible for a patient to stay on either side while suffering from severe tympanites.

On the sixth day the merchant's pulse was 140 and the temperature 101.3 degree F., which proves, if nothing else does, that he did not have diffuse peritonitis, for it is impossible for a patient to have _acute, diffuse peritonitis, _be drugged and fed, and go through the daily physical examinations such as he was put through, and on the day before the abscess breaks into the bowels show a temperature of 101.3 degree F. The pulse counts for nothing in such a case as this; I did not look upon the farmer's pulse as indicative of any serious state, for I knew the opium had caused it. If the pulse of either the merchant or the farmer had been due to peritonitis death would have ended either one before his abscess had broken. In fact diffuse peritonitis comes from perforation with discharge of the abscess contents into the peritoneal cavity, and it always spells death.

When vomiting recurs, or continues after the third day, there is malpractice, or there is a serious complication, or there is a mistaken diagnosis.

It is well to get this one fact well in mind, namely, appendicular and typhlitic abscesses are not accompanied with complete obstruction; hence, when the symptoms are so profound as to point to absolute obstruction, no delay should be made in having the abdomen opened and the obstruction, whatever it is, should be removed at once.

The fact that the bowels do not move in from twelve to twenty-one days should not be looked upon as total obstruction. What obstruction there is is due to fixation of the parts and is truly a physiological rest--it is on the order of the fixation of an inflamed joint--the joint appears to be anchylosed, but as soon as the pain is gone it becomes as movable as ever.

Again, if the case is really obstruction it will grow worse daily even if my plan of treatment--absolute rest from everything--is carried out to the letter.

There is not any danger of the abscess opening anywhere except into the bowels, for that is in the line of least resistance and, if it fails to do so, it is because it is badly managed.

CHAPTER IX

_I have appendicitis; what shall I do to be saved? _Don't eat anything until well. Use a stomach tube and wash out the stomach; then use a fountain syringe and wash out the bowels; take a hot bath as hot as can be borne, and stay in the tub until all the pain is gone, or as long as possible; then go to bed, put ice on the bowels and keep it on until the temperature is reduced to 101 degree F., then apply hot applications or poultices and continue the poulticing until the bowels move, and the bowels will not move until the abscess breaks.

Use an enema every night as a routine, and drink all the water desired, when there is no nausea.

Don't manipulate the forming abscess, nor allow anyone else to do so.

If you are really in doubt about what you have, think over what I have written about strangulation or positive obstruction, and if you think you have it, send for the best physician you know and get his opinion of whether you have obstruction or not, but don't allow him to burst an abscess with his manipulations! For, my word for it, if he can't weigh symptoms and tell whether or not you have complete obstruction without punching holes in you with his bimanual manipulation, neither would he be able to do so after examining you.

I do not say this because I like to make it hard for doctors, but I prefer staying the heavy hand of the doctor to keeping still and allowing him unwittingly to kill his patient.

First of all wash the stomach out with a siphon tube, then see to it that nothing but water goes into the stomach until the bowels move.

I put my cases on a complete fast, give no drugs, apply ice to the region of the appendix, keep the feet warm, and keep the patient in an atmosphere of hope and belief in his recovery, and a recovery always follows. I prescribe an enema of warm water once or twice daily, getting all the water possible into the bowels.

These patients are so comfortable after the second or third day that it is hard to make them or their friends believe that they have appendicitis People are so afraid that they will starve to death if they have no food for a few days that they make haste to get put on a killing treatment rather than run any risk. This fear is absurd Physicians are largely to blame for this popular ear, for those who do not feed by mouth still have the idea that their patients must have nourishment, so they feed by r.e.c.t.u.m. This is also absurd. What the patient needs is rest, and the more complete the rest the quicker the recovery. Give the patient all the water he wants.

The bowels will move in fourteen to twenty eight days from the beginning of the attack. Then the fast can be broken by giving a gla.s.s of hot milk, which is to be chewed well, or given in the form of junket; this is to be repeated three times a day for a week, or give the milk twice a day and a plate of mutton broth for the third meal. I do not give solid food because there is a large abscess cavity opening into the bowels, and if solid food is given before it has time to close, it is liable to find its way into this cavity, thereby preventing healing, and bringing on a chronic condition that will ultimately end in death. The less food taken for one week after the discharge takes place, the better. Any rational individual should see that withholding food is the proper treatment. Milk should be thoroughly mixed with saliva or not taken at all. Remember that if milk is not taken with great deliberation, and great care given to _thoroughly insalivate each sip, then it amounts to the same thing as eating solid food._

Milk is a solid food when taken into the stomach as a beverage or a drink like water.

In appendicitis all nature cries out for rest, and if it is given 99 out of every 100 cases will get well and there will be no suffering and no danger after the first seventy-two hours.

The ordinary physician sends for a surgeon, and if he is a victim of the surgical mania the patient must be operated upon at once, for if twelve or twenty-four hours are given, the conditions may clear up and an operation will be unnecessary. The majority of surgeons feel that they will forfeit their right to heaven if they do not cut at once. The consequence is that there are many patients operated upon who are as innocent of having the disease as the surgeon is innocent of a knowledge of a better plan of treatment.

Of course, the surgeon declares that pus should be let out by cutting into it, or it is liable to break into the peritoneal cavity and cause death This is positively not the truth, for when an abscess threatens, nature at once proceeds to throw a wall around in order to avoid accidents. All around the point of prospective abscesses, heavy walls of adhesions are built, and if nature is not interfered with, the abscess will break into the gut, because it is the point of least resistance, and it is also the point favored by gravity. The surgeons when they operate in these cases work exactly opposite to nature.

If these abscesses are allowed to open into the bowel and solid food is kept away from the patient, full and uncomplicated recovery will take place. If solid food is given too soon it is liable to find its way into the abscess cavity and cause a blind fistula, which may take on acute inflammation at any time. These cases then become chronic and are called recurring appendicitis. It is sound surgery, in dealing with abscesses, to find, if possible, the direction nature is taking to evacuate pus and be guided by this suggestion in evacuating a pus cavity.

In order to cure appendicitis you must remove the cause. Cutting off the appendix, opening an abscess, withholding food till the acute symptoms have pa.s.sed; such treatment is not removing the cause.

Nothing short of changing the eating habits of the patient will cure, so the surgeon who knows nothing about food and its action--what part improper eating has to do with bringing on the disease--will never be able to cure.

Operating for this disease will fall into disrepute in time, for there are already cases recurring and the second and third operation will be necessary among those who survived the first. There is not a scintilla of logical reasoning in defense of the operation. Because some get well after an operation is no proof that the operation was necessary; fortunately for the operator there is no way to prove that the case operated upon would have recovered without the operation. If the case be not complicated by bungling treatment an operation is uncalled for. If a case has been medicated and fed to death--abused to the extent of causing a rupture into the peritoneal cavity--surgery must be resorted to as the only hope.

If a case survive an operation the patient is no wiser than he was before, and knows nothing about avoiding another attack, for let it be said loud enough to be heard by all, and with no fear of successful contradiction, that if every child at birth should have the appendix removed there would not be one case less of appendicitis than there is with the appendix intact. Of course, technically there could be no appendicitis without an appendix, but the cec.u.m would become inflamed just as readily.

No amount of forcing drugs given by the mouth can induce a movement from above the constriction, but a great amount of pain can be produced by attempting to force a pa.s.sage. No one comprehending the true state of affairs would be foolhardy enough to try to force the bowels to move. The reader can readily imagine the great pain and danger liable to follow cathartic drugs, for they stimulate severe peristaltic contractions. The contractions drive the contents of the small intestine against the inflamed cut-off, but there it must stop. If the parts have become softened, which they do by the inflammation, there is danger of perforation and an escape of the contents of the bowels into the peritoneal cavity, after which diffuse peritonitis and death follow. Surgery can hardly hope to save such patients; in fact they usually die; this is why the surgeon recommends an early operation.

If all cases are to be so abused and if there were no better way to treat them I also should say, operate at once as soon as the disease is discovered; but I know from years of experience that there is a better way to care for these patients.

CHAPTER X

Allow me to repeat: As soon as a case is diagnosed the proper treatment is to stop all medicine and food, for they excite movement, and this should be avoided. Give nothing but water. Keep ice over the inflamed spot. Keep the patient quiet, end the feet warm. There is absolutely nothing to be done until the bowels move, which will take place in from fourteen to twenty-eight days. The patient will not starve to death, nor will there be any danger that the abscess will open anywhere except into the bowels. After the bowels move, one gla.s.s of hot milk is to be given three times a day, so there will be no danger of solid food finding its way into the cavity of the abscess.

To be safe I insist on a fluid diet for a week after the bowels move, and a light diet for two or three weeks more. Cases taken through in this way, and then instructed in never allowing the bowels to become loaded again, will not only make a good recovery, but there is no tendency for the disease to return if the patient is prudent. I say that there need not be a death from this disease if these suggestions are properly carried out. The cases that die every year are killed by food and medicine.