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

Treatment: I believe that contrasting treatments is the very best way to teach; however, this plan is not so good when carried on in writing as it would be clinically.

In order to contrast my treatment with the best just now available I shall quote from one of the latest authorities, “Modern Clinical Medicine—Diseases of the Digestive System.” Edited by Frank Billings, M. D., of Chicago. An authorized translation from “Die Deutsche Klinik” under the general editorial supervision of Julius L. Salinger, M. D. Published by D. Appleton and Company, 1906.

It is reasonable to believe that when one of our leading American physicians thinks enough of a foreign author to translate his productions the material must be pretty well up to the top of medical literature, and that is my only reason for selecting this particular contribution on which to make my comments for the purpose of contrast.

The case I select is strictly in line and parallels a case of my own. It is a case of Diffuse and Circumscribed Peritonitis, treated and reported by O. Vierordt, M. D., of Heidelberg.

“Acute, Diffuse Peritonitus: As an introduction to the discussion of our present views of acute peritonitis I will relate the following clinical history:

“Case 1.—A previously healthy merchant, aged 31, was taken ill after a few days of vague, dull pain in the right side of the abdomen which he had disregarded, and upon the 20th of October, about midday, he was seized with very severe pain in the right lower abdominal region which compelled him to seek his bed; soon afterward he had chilly sensations which increased to marked chills; there was also nausea, eructation and vomiting, first of food and then of bilious mucus; a little later tenesmus appeared, the patient first voiding small, compact feces, followed by scant, thin dejecta. Within a few hours the abdomen had become tympanitic, the pains continued with exacerbations upon motion, after eruetations, and on talking; the entire abdomen was very sensitive. Strangury with the frequent discharge of scant urine was observed.

“Toward evening the physician found the patient extremely ill, immovable in the active dorsal decubitus, with an anxious facial expression, reddened cheeks, cautious, superficial respiration with a low, hushed voice; he complained of continuous, also occasionally of marked tearing and contracting pains in the entire abdomen, most severe upon the right side low down; the temperature was 103.2 degree F., the pulse was 112, full, somewhat tense, regular and even.

“The lips were dry, the tongue markedly coated; foetor ex ore was present; painful eructations were frequent, also singultus, complete anorexia and extreme thirst. The respirations were superficial, quite rapid, and purely thoracic; the diaphragm was slightly raised; the pulmonary-liver border was, in the right mammillary line, at the lower border of the fifth rib; upon anterior examination the thoracic organs appeared normal; the examination of the back was not then undertaken.

“The entire abdomen was uniformly tympanitic, everywhere very sensitive to the slightest pressure, but more so upon the right side than upon the left. There was also pain upon pressure in the lumbar region.

“Signs of abdominal respiration were absent. Careful palpation showed a uniform, drum-like resistance, otherwise nothing abnormal. The percussion note over the abdomen upon light tapping (and only this could be borne) revealed no decided difference, and nowhere any dullness; upon prolonged continued auscultation, high-pitched intestinal murmurs were here and there heard.

“Retraction of the thighs produced diffuse abdominal pain, more marked upon the right side than upon the left; careful examination of the hernial rings gave a negative result.

“Upon careful digital exploration per rectum in the dorsal decubitus, nothing abnormal was noted except pain in the floor of the pelvis; the rectum was empty.

“Since morning neither feces nor flatue had been passed; the patient complained of strangury which, however, he rarely attempted to relieve because he feared to aggravate the pain which shot downward and radiated into the urethra. The urine was of high color, clear, and contained a trace of albumin and large amounts of Indican.

“The physician in charge of the case diagnosticated acute, diffuse peritonitis, the origin of which was not quite clear; very likely it was in the appendix. He ordered absolute rest, that the urine and feces be voided in the recumbent posture; that, for the present, only small quantities of ice be taken by the mouth;”

[First mistake. Never use ice nor ice water to relieve thirst for it creates an unquenchable thirst and causes nervousness and general discomfort, not only in this disease but in all others.]

“that two bags filled with ice be applied to the abdomen, and be suspended from a hook if they could not be borne directly upon the abdomen. Furthermore, at first every two hours, later somewhat less frequently, 0.03 of opium purum in powder form was to be taken in a little water.”

[Pure opium 0.03 or 6/13 grain every two hours at first, less frequently later, was the second mistake, for opium brings on general depression. It not only dulls sensation, but it inhibits combustion thereby lessening nerve supply, weakens the heart action, and masks the physiological as well as the pathological state. The disadvantages of such an influence should be apparent to even a medical novice. The influence of opium in inhibiting nerve supply reduces the normal irritability—muscular tone; this works a great disadvantage in bringing about a tympanites entirely out of keeping with the intensity of the disease and this is not the only artificial symptom induced by this drug as we shall see later.

An opium tympanites causes many physicians to mistake it (a drug-action, or a symptom induced by drug-action) for the tympanites caused by peritonitis. The great disadvantage of thus masking and perverting symptoms, which should be natural so that the physician can know at any hour of the day just exactly where his patient is, must certainly present itself even to a lay mind.

It surely is important to know that an opium-induced, phantom peritonitis causes pressure upon the diaphragm, which in turn crowds the lungs and heart, inducing precordial oppression—smothering sensations and simulating important symptoms which should be understood at once so that a proper remedy may be applied.]

“In the following forty-eight hours, with irregular variations and a slight tendency to rise, the temperature ranged between 102.2 degree F., and 105.3 degree F. The pulse became more frequent but remained strong and uniform; the respirations were unaltered in character but increased in frequency to 48.”

[Unnatural and brought about by opium.]

“The patient, unless under the influence of opium, was sleepless, his mind was clear, and he gave the impression of being extremely ill, although not in collapse.”

[This is peculiar to opium; it was too early for these symptoms to develop in this case; hence drugs brought them on.]

“The pains, eructations and vomiting were decidedly relieved by the opium;”

[A relief that was bought at a tremendous cost, for a time came in a very few days when it was hard to tell whether the vomiting was from the disease or from the drug. The increase in respirations was due to opium.]

“but ice-bags for a time were not well borne and cold Priessnitz compresses were substituted. Vomiting was rare, was invariably bilious and coarse-grained; neither feces nor flatus were discharged; the urine was as before the diazo-reaction negative.

“Distention of the abdomen and the area of diffuse resistance increased; sensitiveness to touch appeared to be dulled by the opium; in the ileo-cecal region, however, it was constantly severe and lancinating. The liver dullness below decreased;”

[Why not? Extending tympanites caused it—insignificant at most.]

“the pulmonary-liver border extended to the upper border of the fifth rib; on the right side of the abdomen between the navel and the anterior, superior spine of the ileum a circumscribed slight dullness was observed.”

[This could have been taken for granted without unnecessary palpation.]

“There was great nausea and burning thirst.”

[Already the opium was getting in its work. Great nausea and burning thirst were not due to the disease, and the crowding upward of the liver border was caused by the gas distention.]

“Diagnosis: Acute diffuse appendicular peritonitis, probably also perforation; circumscribed perityphlitic abscess.”

[The diffuse peritonitis was apparent to the eye but not to the reason as the course of the disease proves before many days.]

“Operation was considered but not performed. Removal to the hospital for the purpose of an operation was absolutely declined by the patient.”

“I saw him upon the following day, the fourth of the disease.”

[Undoubtedly this case had advanced to the seventh day when the description began.]

“In general the severity of the clinical picture had increased, especially some of the individual symptoms: Severe, markedly febrile general condition; pulse 120 to 136, moderately full, regular.”

[Drugs and food caused the increase in the severity of the symptoms, for if the increase in pulse and temperature had been due to toxic infection, there would have been no amelioration of these symptoms, which we find takes place later.]

“There was insomnia with occasional opium slumber; otherwise the mind was clear but anxious. The tongue was thickly coated, the lips were dry, there was tormenting thirst.”

[Ice and opium were getting in their work, increasing the nervousness and of course the fever.]

“The cheeks were red. The patient maintained the dorsal decubitus with feebly flexed legs and hushed voice; the hands moved but slightly and trembled.”

[Narcotism.]

“Occasionally there were spontaneous attacks of severe, tearing, abdominal pain, starting posteriorly in the lower right side.”

[Why not? Food was being given, stimulating peristalsis.]

” The abdomen was very tympanitic and tense, and could scarcely be touched; nevertheless, it was possible to determine upon the right side low down an area of dullness about the size of a hand with increased resistance; otherwise the note was tympanitic upon percussion.”

[The reader will notice the frequency of the reports regarding the area of dullness and extension of tympanites. These frequent examinations are wearing on patients in this condition, and are of no consequence whatever; they start at nothing and end nowhere, except in the discomfort and often the death of the patient; they are practiced by too many physicians and should be discouraged for they represent a very bad habit and are harmful; they are pushed to a pernicious extent in some cases, for without doubt abscesses are ruptured by them. If the physicians were not satisfied by this time without the need of laying on of hands, observation and analysis were lacking.]

“The diaphragm was raised; except for a small zone liver dullness was absent.”

[Of what possible benefit was this