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

knowledge under the circumstances?]

“Now and then there was grass-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 circumscribed 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 circumscribed perityphlitic abscess.” How was it possible with meteorism as described, to say that there was a sharply circumscribed perityphlitic abscess? It was tacitly assuming 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 cecum, 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 circumstances 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 passing 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.”

Can there be any wonder that this disease is so fulminating in the hands of the average medical man or can there be any surprise at the death rate? If such an examination were given to a well man and repeated as frequently as in the average appendicitis case, I say that the well man would soon suffer from some severe disease induced by bruising.

When appendicitis or typhlitis ends in an abscess, and the pus sac is ruptured by meddlesome, unskilled treatment, scientific or otherwise, causing the pus to burrow toward the groin, surgery is the only treatment; there is no hope of recovery in such a case without establishing thorough drainage, and this means skilled surgical treatment. It will positively be a miracle if such a patient recovers without an operation. I have seen these cases linger for two, three, and even five years. The type of cases that lingers so long is one that has an imperfect drainage, either into the bowels or through a fistulous outside opening.

What per cent of cases is of this type? That is hard to tell for the world is full of unskilled, heavy-handed manipulators.

I have seen quite a number of this type who had been brought into this unnecessary state by bungling doctors who were treating them for typhoid fever and its complications.

I say without fear of successful contradiction that there never was and never will be such a case unless it is made so by the worst sort of malpractice.

The fact that a diagnosis was made in spite of the tympanitic distention is proof that a dangerous force was used in doing so, converting a typhlitic abscess into a perityphlitic one, and doubtlessly causing premature rupture into the bowel. Any professional man, with the right regard for his patient’s welfare, and the judicial understanding that qualifies him for taking the responsibility of directing the treatment of so important a case, would scarcely have laid the weight of his finger on an abdomen in such a dangerous condition. The symptoms and course of the malady up to that time should have told the real diagnostician that there was an abscess and that the abscess would rupture into the cecum if it were not meddled with.

No one with a proper understanding of his responsibility in such a case would have thought of undertaking an operation with a patient in the physical condition that this man was reported to be in. “The long continuance of the severe symptoms” is proof positive that the “severe symptoms” were false or man-made.]

“Morphine was ordered subcutaneously, Priessnitz compresses to the abdomen, pellets of ice and meat jelly by mouth; eventually gastric ravage.”

[Under the circumstances this was positively murderous. Acknowledging to such treatment forces me to declare that the witness is incompetent, on the ground that no one has a right to incriminate himself. Nothing but the most positive malpractice could have brought a case of this kind to need gastric ravage, at this age and stage of the disease.]

“Upon the sixth day of the disease the picture changed.”

[It is impossible for any case to arrive at this state of maturation in six days, if allowed to take its own course.]

“The complexion became sallow, the face elongated, the eyes hollow; the pulse was 140, small, but quite regular; the temperature was 101.3 degree F.;”

[The great discrepancy between the pulse and temperature was caused by the opium.]

“there was clammy perspiration and a cool skin, the hands were cold; frequently slight eructations occurred and, now and then, ineffectual or mild paroxysms of vomiting of a greenish yellow material with a slight fecal odor.”

[All these symptoms were positively unnecessary. They were built by food end drugs.]

“The mind was clear; there was little pain.”

[There was no reason why the mind should not be clear, and there should have been no pain after the third day.]

“The abdomen became somewhat softer, much less painful, and was readily palpated and percussed; there was a distinct resistance about the size of a hand, quite firm, and not fluctuating, and accompanied by marked dullness, around McBurney’s point and downward, and only in this region severe stabbing pain; in other areas no dullness.”

[The sallow complexion, elongated face, hollow eyes, pulse 140, temperature 101.3 degree F., clammy skin, cold extremities, greenish vomiting with fecal odor; all these symptoms would have been ominous of a fatal collapse had it not been that the symptoms were those of narcotism, and not the symptoms of peritonitis as they were supposed to be. The small, regular and frequent pulse, the clammy perspiration, cool skin, cold hands, the eructations and mild paroxysms of vomiting of greenish yellow material with fecal odor, were symptoms produced by opium, food and morphine, as should have been fully apparent to any medical mind.

If the patient had been treated rationally from the start, at this stage of the disease he would have been as comfortable as at any time in his life, and after the opening of the abscess, forced though it was and followed by those symptoms, the patient still had a chance to get well if he had been left alone. See how he responded when given a little opportunity. Only twenty four hours after “the intake of food was reduced to almost nothing” the abdomen was softer and readily palpated and percussed. Just imagine, reader, what a difference there would have been in this case if the poor, miserable victim had been allowed the quiet he so much needed—if he had been left without daily bimanual examinations, food and drugs. The patient was kept in an abnormal state from the first hour that the doctoring began to the last hour of his life.]

“The symptoms were those of moderately severe peritoneal collapse;”

[In all the cases I have ever seen, I never knew of one showing any symptoms of collapse when the abscess ruptured.]

“the prognosis was very grave although not positively hopeless.”

[If the symptoms had not been those of drug and food poisoning they were very grave.]

“Treatment: Small quantities of alcohol, to be followed by camphor.”

[All the treatment necessary was absolute quiet—no drugs, no food—nothing until nature had time to react fully; then there would have been a full and speedy recovery. Alcohol and camphor were injurious to a body already suffering from opium paralysis, for all such drugs are heart depressants.

As I have said for years: The physician who gives drugs can’t possibly know where his patient is. “Peritoneal collapse!” If there had been no narcotism there would have been no appearance of collapse. Every symptom giving the appearance of collapse was due to opium and morphine. I have seen such collapses for I have made them, and I have