Appendicitis by John H. Tilden (life books to read txt) ๐
APPENDICITIS
CHAPTER I.
This cut represents the back view of the cecum, the appendix, a partof the ascending colon, and the lower part of the ileum, with thearterial supply to these parts.
"A, ileo-colic artery; B and F, posterior cecal artery; C,appendicular artery; E, appendicular artery for free end; H, arteryfor basal end of appendix; 1, ascending or right colon; 2, externalsacculus of the cecum; 3, appendix; 6, ileum; D, arteries on thedorsal surface of the ileum."--Byron Robinson.
The reader will see how very much like a blind pouch the cecum is,2. The ileum, 6, opens into the cecum, all of the bowel below theopening being cecum, the opening of the appendix, 3, is in the lowerpart of the ce
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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 natureโs 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 abdomenโthe bowels and all involved and contiguous partsโbecame 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 โabout midday; he was seized with very severe pain.โ 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 canโt 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 โAcute, Diffuse Peritonitis.โ 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 doesnโt 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 fingeredโthumbed 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 wifeโs 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 wonderโfear 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 fixationโthe embargo laid on these parts by nature in her conservative effort at preventing movementโis 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
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