"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. There was a fresh relapse of the local peritonitis which extended beyond the boundaries of the limiting adhesions, and permitted the invasion by bacteria of the free abdominal cavity. This, time the severe toxic picture of collapse immediately followed, and with marked decrease in cardiac strength led to death.
"Doubtless the patient might have been saved in the first stages of the disease by the evacuation of the abscess; the incision would at first have acted similarly to spontaneous rupture into the intestine, but the relapse would have been prevented by permanent drainage, and a radical cure might have been brought about by the immediate or subsequent removal of the appendix.
"Opium, no doubt, had a favorable effect upon the affection. By relieving intestinal irritability, and by bringing about a mild degree of narcosis, the patient was kept quiet and this materially assisted in limiting the severe perityphlitic suppuration in the first stage of the disease."
[All of which is positively not true, as I have witnessed for years.]
"If, as it unfortunately happened, the point of rupture had not immediately closed again, if it had remained open until suppuration ceased and contraction and healing of the perforated appendix had taken place, opium would have been regarded as instrumental in saving the patient, and unquestionably, at least to some extent, justly so. Among other factors in the treatment, the relief to the intestine by the suspension of nourishment was of paramount importance. The subcutaneous saline infusion had an obvious but, naturally, only a transitory effect."
The subcutaneous saline infusion is another ridiculous habit. It would really be amusing if it were not so tragic, to see patients driven to the edge of the great divide and then see the innocent doctor throw out an impotent life line.
The absolute innocence displayed by this professional man, from first to last, his belief in himself and the mechanism of his theory and practice exculpate him from the charge of carelessness, neglect of duty or even that he didn't know what he is doing. He does know what he is doing in a way. He works as exactly as a Waltham watch and he thinks about as much as the stem that winds the watch.
I cannot agree to the summing up of this case. There was not at any time, previous to the relapse and death of this patient, what we understand as peritonitis. A post-mortem examination might have shown the intra-peritoneal covering, of that portion of the cecum involved in the inflammation, slightly inflamed, but it is not reasonable to believe that the inflammation was of a toxic character unless adhesive inflammations can be so called.
Inflammation is always the same, it matters not what the _exciting cause _may be. It is an exaggerated physiological process. If there is inflammation of any part of the body it means that there is an exaggeration of function. Its intensity will be in keeping with the exciting cause. If the cause is intense heat or cold, or a corroding acid or alkali, the local action may be great enough to destroy the part; the inflammation following will be of the contiguous structure outside of the killing range of the cause, and it will be a simple—non-toxic—inflammation unless the secretions thrown out in excess of the reparative need are retained by dressings or prevented in some other way from draining away. If these secretions are kept bound on the raw surface by dressings until they decompose—yes, until the fermentation causes germs—the wound will become infected, and to what extent will depend upon the amount of malpractice—carelessness or ignorance—to which the case is subjected.
If the inflammation is caused by decomposition or a toxic agent, the extent of the process will depend upon the integrity of the part infected and the state of the general health, also upon the local environment—such as pressure interfering with the circulation of the blood.
In this fatal case there was the constitutional derangement and the toxic state of the alimentary canal; then there was the exciting cause, sufficient to create a local infection the symptoms of which were given at the beginning of this description, and which lasted for a few days; during which time the patient, no doubt, was eating and possibly taking home remedies to move the bowels, etc. These preliminary symptoms were followed by a severe pain in the right lower abdominal region, followed with chills, fever, nausea, vomiting and later by painful movements from the bowels, small in character, and soon after this distention of the bowels from gas.
During the few days of preliminary symptoms nature was going through the usual preparation of fixing the parts. The muscles were becoming rigid, which is one of nature's plans for protecting an inflamed part; the infection was striking deeper and arousing all the defenses. Possibly there had been a local inflammation of long standing, gradually degenerating into a fecal ulcer, which means that there was a spot of ulceration deep enough for fecal accumulation and the accumulation created fresh infection, which lighted up an active inflammation setting all the parts into defensive activity. The muscles of the abdomen—the bowels and all involved and contiguous parts—became set or fixed; and when this rigid state became established, the bowels below the cecum refused to receive the contents of the small intestine; hence when the peristaltic movement started at the head of the small intestine it found that an embargo had been laid on the cecum and lower bowels so that nothing could pass. This embargo took effect "about midday; he was seized with very severe pain." What was this pain? What is the pain that always attends obstruction of any kind? It is the desire for the bowels to move when they are unable, on account of the stoppage, to do so. Is there a reader who can't conceive of the terrible suffering that must come from such a state of the bowels, The pain is not from the spot inflamation, or ulceration, or the forming abscess, whichever is the exciting cause of all this trouble; for, if it wore, the pain would not stop in three days, or after the patient has been fasted long enough for the peristaltic movements to subside side. No, the local inflammation is not sufficient within itself to cause any more pain than this patient had the few days before he went to bed; it takes obstruction to bring suffering, and even obstruction will not cause pain _per se, _for this is proven in all cases rightly treated. As soon as the stomach and upper bowels are rested from food and drugs, all pain is gone and will never return unless the patient is badly handled.
In this case opium and morphine were given; this was very bad treatment, for these drugs always produce nausea and vomiting, exactly what was not desired because of the evil effect the retching had on the forming abscess. It is true that these cases frequently vomit the first three days after the obstruction, but there is practically no danger from retching that early in the disease. Again, the opium masked the case dreadfully; for it produced vomiting at that stage of the case when there should have been no trouble with the stomach at all, and induced a tympanites that was mistaken for the same state brought on by peritonitis.
In this case the doctor was in a mental mist from the beginning to the end; notwithstanding he was so confident that he knew all about his patient, that he has given the case a careful summing up so that it may be put with the medical classics.
The doctor is in error when he gives the name of "Acute, Diffuse Peritonitis." The case could not have been peritoneal perforation at the start, for the symptoms do not justify the diagnosis. A perforation causing diffuse peritonitis so early would have a higher pulse and temperature, and death would have followed within a few hours.
I can believe that there might have been an ulcer extending to the peritoneal covering, and this set up local peritonitis; but there was not at any time before the fatal relapse, a toxic inflammation within the peritoneal cavity; hence there was not diffuse peritonitis, and there could not have been without complete perforation which would have ended the case in death very soon.
In this case the point of infection was walled in, as all such cases are, with exudates and whether the appendix was primarily affected or not doesn't matter; it was within this enclosure and found to be ruptured, which is common; but its rupture was of no consequence because the escaped contents were in the abscess cavity that finally emptied into the cecum, the natural outlet in all these cases if they are left to nature and not officiously fingered—thumbed and punched to death.
The distinction drawn by this author between toxic and bacterial peritonitis is, to my mind, a distinction without a difference.
In this case the tympanites following the obstruction was due to the fact that the gas in the bowels was retained for a few days because of the completeness of the obstruction, and would have passed off in three days had it not been for the paralyzing effect of the opium; hence the distention that came from gas was succeeded by the distention peculiar to opium and caused the doctor to believe that he had a case of diffuse peritonitis when, in fact, he had a case of gas distention due to morphine paralysis. The morphine directly and indirectly weakened the heart. The distention of the bowels was a constant interference. The pulse at the start was fine at 112, but in six days it had increased to 140 and finally reached 160.
The following case comes to my mind, for some of the initial symptoms are similar to those of the case just described: M. B., age 42, farmer, was taken sick with the usual symptoms of appendicitis as near as I could get the history from his wife, who was his nurse. He lived twenty miles from Denver. When he was taken sick he called a local physician who treated him for _bilious diarrhea. _The drugs used, as near as the wife could remember, were small doses of calomel followed with salts to correct the I liver, morphine for pain, and bismuth and pepsin for digestion and diarrhea, and quinine to break the fever; also hot applications on the bowels.
The pain was so great that morphine had been given quite freely. At the end of one week the sick man, being no better, declared that he would go to Denver and consult another physician. When he told his physician what his intentions were, the doctor advised him not to attempt the trip himself, for he was too sick, but to send for the physician. The sick man was willful and forceful, and he was also afraid of the cost; and, being a plucky fellow, he declared that he could go just as well as not and that he would and he did.
His wife was a large, strong woman and gave him valuable assistance, but I never have understood how it was possible for so sick a man to make the journey from his home to my office. He was obliged to help himself a great deal in climbing in and out of ordinary conveyances to reach the train and, when in Denver, with his wife's assistance, he walked a half block to the street car; then from the car to my office he was obliged to walk one block and at last climb one flight of stairs. When they came into my office the wife was almost carrying him. I saw at a glance that he was a desperately sick man, and before I attempted to examine him I had him lie down for a while.
He had no history of any previous sickness; he had always been very healthy, and his life had been spent in hard work in the open air.
The general appearance of the man was that of one suffering from diffuse peritonitis. The abdomen was enormously distended; this symptom more than any other caused me to fear and wonder—fear that rupture would take place before he could be put to bed, and wonder how it was possible for a man to be out of bed and go through what he had gone through that morning without causing a fatal injury of some kind. The distention, I was informed, had been gradually coming on from the first, and he had been given morphine to control the pain from the first day of his illness. When they gave me this information I knew that the tympanites was due to narcotic paralysis, instead of coming from perforative, septic peritonitis, as the general appearance and symptoms indicated. This reasoning gave me hope in spite of the formidable appearance of the case.
The pulse was 130, temperature 102 degree F., in the forenoon; he had been troubled with nausea a great deal, but with the exception of one or two vomiting spells, the first and second day, the nausea did not often cause retching. The mouth and lips were dry, tongue coated, bad taste in mouth and breath very offensive.
The reason there had not been more vomiting in this case was because there was diarrhea at first and not quite so much locked up fecal matter as common. The bowels had been relieved of the usual accumulation more than is common to the majority of such diseases before the swelling and fixation had become established.
There is a small percentage of people who are not quite so irritable as others; in these the contraction, constriction or fixation—the embargo laid on these parts by nature in her conservative effort at preventing movement—is not established quite so early, and the efforts on the part of doctors to force a movement are more successful in cleaning out a part of the accumulation; or there may come a diarrhea from the putrefactive poisoning which is causing the infection of the cecum or appendix and leading to abscess, and this causes a partial cleaning out before fixation is established; in these cases there is never so much vomiting nor nausea, neither do they suffer so much pain for there is not the usual accumulation in the alimentary canal to excite the peristaltic movement.
The history that the patient and his wife gave me from memory was that the urine had been scant, and at times painful to pass. There had been from the start severe pain in the lower bowels, but neither the patient nor his wife could remember if there had been more pain on right, lower frontal region than anywhere else; they both declared that the pain was all through the bowels and that there was much bearing down like unto the pain of a diarrhea.
Breathing was shallow, of course; it never is otherwise in severe abdominal distention.
I scarcely touched the abdomen, for I knew I dare not press, in percussing, enough to distinguish any sound except the tympanitic. It has never been my custom to allow my curiosity to run away with my judgment, and cause me to make needless examinations.
All examinations are needless when, it matters not what the diagnosis can or must be, the treatment will be the same. All possible bowel troubles which present the same general symptoms of the disease I am here describing, must receive a like general treatment. This being true, it matters not what the difference is, there cannot be a variation requiring a bimanual examination to differentiate it that will justify the risk. All examinations are needless and criminal when there is a possibility of rupturing an abscess. Especially is this true when it is a_ positive fact _that all typhlitic and appendicular abscesses will open into the bowels if allowed to do so.
In this ease I reasoned as follows: This must be a case of abscess, for the signs of obstruction are not those of complete obstruction, such as are seen in hernias, volvulus, constricting bands and many other causes not necessary to mention. If there were complete obstruction there would be increasing nausea and vomiting, ending in collapse and death. This tympanites cannot be from peritonitis for perforation would be necessary to cause it and nothing would stop the progress after it had once started except to open the cavity wash and drain. Hence this cannot be peritonitis, for there has been no operation and the patient still lives. It can be distention from the effects of morphine, but there must be more than morphine paralysis, for there is a temperature of 102 degree to 103 degree F., and there has been, so the wife says, a temperature of 104 degree F. The pulse rate being 130 does not indicate fever nor exhaustion, and is not in keeping with the temperature nor physical strength, hence the rapidity must be partly due to pressure on the diaphragm from the gas distention and partly from the paralyzing effect that opium has on the heart.
The professional reader will see that I have by my analysis eliminated much of the formidableness that the physical appearance gives to this case, but I would not have you believe that this man was not a desperately sick man even if I have accounted for the dangerous symptoms. The fact is, if the pronounced symptoms had been what they appeared to be, the man would have been saved his trip to me, for he would have been dead.
The farmer had learned from experience that the less he put in his stomach the better he felt; hence, for a day or two before he left his home to consult me, he had refused food and drugs and had taken very little water.
After giving the sick man a rest in my office I had his wife take him to the home of a friend with whom they had arranged to stay while in the city. In a few hours I visited him and made the following prescriptions and proscriptions: Positively no food, not one teaspoonful of anything except water. An enema of half a gallon of tepid water to be used once each day for the purpose of clearing out the bowels below the constriction, and I advised against violence—rough handling. A hot water jug to the feet, fee to the abdomen, all the fresh air possible in his bedroom and absolute quiet. If nauseated, enough water to control thirst was to be used by enema; if the stomach was all right all the water desired by mouth.
I called the second day; the patient had slept some—he thought about three hours of broken rest—feeling fairly comfortable; pulse 120, temperature 101 degree F. at 9:00 a.m.; 102 degree F. at 5:00 p. m. Third day: Temperature 100 degree F. at 9:00 a. m.; 101 degree F. at 5:00 p. m.; one-third of the tympanites gone; slept six hours; hungry and demanding food. I said, "No, you get no food until the bowels move." The ice was taken off the bowels; hot cloths were substituted.
The fourth day the temperature in the morning was 100 degree F.; in the afternoon 101 degree F., pulse 100; slept well, hungry, bowel distention reduced fifty per cent. I touched him very lightly and found enough to confirm my diagnosis of typhlitic abscess; this was the first time I had felt that I was justified in attempting to confirm my suspicions, and even this examination could not be called a palpation, for I put no weight upon the abdomen. The patient was very dissatisfied because I would not allow him food. I said, "No. you can't eat until your bowels move." "How soon will they move!" he asked in an irritating and ungracious manner, to which I replied, "Your God only knows, and He won't tell."
Fifth day about the same, a little better; very ugly because I would not allow him food. He said: "I don't believe there is anything the matter with me; you are holding me down."
Sixth day about the same, feeling fine, sleeping fine and _starving to death. _He made himself so unpleasant by his clamoring for food that I permitted his wife to give him a half dozen Tokay grapes. He had scarcely swallowed the sixth when he had all the pain he wanted. His wife came to my office in great excitement: "Doctor, please come at once to see my husband; he is much worse, he is in agony with his bowels." My answer was: "Go back and renew your hot applications to the bowels and tell your husband I permitted him to eat the grapes because he had been so unkind and ungrateful for the comfort that had been given him; tell him that I knew the grapes would give him pain and that the pain will not wear off entirely for twelve hours, and that I will not see him before tomorrow morning."
I called as I agreed to do the next day, the seventh day since the case came under my management, and the fourteenth day from the beginning of the disease. The sick man was out of humor. To my question, "Would you like something to eat!" he drawled, "Na-a-aw! I never intend to eat any more; but I would like to know when my bowels are going to move." Of course I could not tell him any more than I had told him before, namely, that under such circumstances they usually require from fourteen to twenty-eight days.
From this time on every day was much the same; no elevation in temperature, and the pulse ranged from eighty to occasionally one hundred; no pain, sleep good, that is, as good as people generally sleep who are on a continuous fast—under a continuous fast the sleep is good but not heavy nor long at a time.
It is a fact that when these cases are properly handled they are not sick after the first week; they do not look sick; they get to thinking that it is folly to stay in bed and live without food, and of course their neighbors know that there isn't anything the matter with them; that the doctor is starving them to death. Quite a number of my patients have brought themselves near death's door from disobeying instructions and taking the advice of knowing neighbors. They were persuaded to "eat"—"eat all you want, for the doctor will not know it."
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 quantity 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, washing 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 substitute 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 glass 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.
_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 rectum. 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 glass 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 tothoroughly 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 passed; 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 cecum 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 passage. 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.
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 glass 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.
Surgery has gained its reputation in these cases because of the stupidity of the average physician and patient. Cases taken through in this way are comparatively comfortable; they may pretend to suffer from hunger, but it is principally imagination. If my plan were generally adopted the dread of this disease would disappear; surgeons would get left on some fat fees, and the undertaker would look glum after the fall crop.
There are a few laymen so willful and incorrigible that they can't be depended upon to follow instructions. They will break rules, be imprudent in eating, and in many ways disregard their own interests. Such cases should be sent to the surgeons as early as possible, before they have time to complicate their disease and make a complete recovery impossible; however, people with such temperaments usually find an early grave and they might as well go by the surgical route as any other.