Appendicitis by John H. Tilden (novels in english TXT) 📖
- Author: John H. Tilden
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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 to _thoroughly 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
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