Appendicitis by John H. Tilden (life books to read txt) 📕

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 intraperitoneal 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