APPENDICITIS- 6

CHAPTER VI

    Surgical Treatment: Appendicitis is quite generally thought of as an exclusively surgical disease. Osler recommends that such cases be operated upon, and most of the prominent physicians agree with him. The surgeons are a unit for the operative treatment.

    Many surgeons are in accord with Prof. L. ID. Russell of Cincinnati, O., namely, that it is not a question of "when to operate, but how much to operate," meaning that all cases should be operated upon as soon as possible after the diagnosis has been made, but the extent of the operation is to be decided by the conditions found after the incision has been made. If the appendix is surrounded with pus and hard to get at, the indication is merely for drainage at this operation, but if the appendix is accessible, it should be removed.

    Ochsner recommends the withdrawal of all food by mouth, washing out the stomach, leeches to be applied on the abdomen over the inflammation to relieve pain, rectal feeding, and operation in every case after the acute attack is over. If a "competent surgeon" is available he thinks the proper thing to do is to operate during the acute attack, except in a class of very severe cases, which, he says, have a better chance to recover without the operation. I will quote a few paragraphs from his book, setting forth his views:

    "Taking into consideration the pathological conditions described, together with the clinical experience, the likelihood of a recurrence after an attack if no operation is performed, and the likelihood of a complete and permanent recovery if the diseased organ is removed under favorable circumstances, we can come to but one conclusion, namely, that if the desired condition can be obtained the diseased appendix should be removed. "
    "Except in very rare cases in which the entire mucous membrane of the appendix is destroyed during the first attack, it is doubtful whether the patient ever completely recovers unless the appendix be removed. It is more likely, from an anatomical and pathological standpoint, and certainly more in accordance with my clinical observations, that the patient usually suffers from disturbance of his digestive apparatus after recovering from an acute attack of appendicitis."
    " Mynter does not deny the possibility of complete recovery from appendicitis without removing the organ, but considers it an exception or almost an impossibility, and I find that this view is shared by a majority of clinical observers of wide experience."
    "It is rare for an acute attack of appendicitis to subside unoperated without leaving one or more of the pathological conditions briefly described above, and it is plain that with these present the patient must be much more liable to a future attack than he was primarily. In fact, many of the best observers with the largest experience think that recurrence in these cases is the rule and complete recovery the rare exception."

    [The pathological conditions referred to are ulcerated or gangrened appendix, perforations, fecal concretions in the appendix, etc.]
    "It does not matter whether the patient suffers from catarrhal appendicitis, with or without a foreign body in the appendix, or whether the appendix be gangrenous or perforated, he will almost invariably recover if from the beginning of the disease absolutely no food is given by mouth."
    "Some years ago, before I had learned to appreciate the treatment which I now describe, I frequently operated upon patients in just this condition, [condition of patient described as having temperature of 104° F., pulse 140, abdomen very much distended, features pinched and patient delirious!, as a last resort, thinking that this gave them the only possible chance of recovery. Since then I have learned that this case belonged to a class which practically never recovered after an operation, if it is done while the condition is that in which I found this patient, and of which a very large majority recover if the treatment is followed which I have described."

    [The treatment referred to is to let the patient alone except giving food by rectum.]
    "I have had an opportunity to observe a very large number of these patients under this form of treatment, and have operated upon many of them at various intervals after the acute attack through which they were treated in this manner, and have been able to demonstrate that the patient can recover, and practically always does recover, if this method of treatment is employed. Of course, one occasionally encounters a patient suffering from appendicitis who is in a dying condition, and then neither this nor any other method is of any value. "
    "I find that many authors advise rectal feeding under certain conditions, but I am certain that the exclusive rectal alimentation is of greater importance in the treatment of appendicitis than any other single method, but I am equally certain that it must be carried out thoroughly, because even a small amount of food or the administration of a cathartic may suffice to bring about a fatal issue.

    [Why feed! There is no danger of starving!]
    "I am also certain that many patients are enormously benefited by the use of gastric ravage for the purpose of removing a quantity of decomposing material, the absorption of which would certainly do a great amount of harm. I am also certain that gastric lavage does permanent good only if no further food is placed into the stomach, which would result in further decomposition."
    [At the beginning of treatment--the first visit --wash the stomach and then feed no more.

    Although some physicians boast that this is an age of preventive medicine, the following paragraph is about all that is devoted to this phase of the subject. In one or two places people are cautioned not to eat too much and chew thoroughly, but what does this amount to? How many people know how much to eat or how thoroughly to chew ? Very few physicians have a grasp of this subject.]

    "It is true that recurrences can usually be prevented by careful attention to diet, by securing daily free evacuations of the bowels, by avoiding over-work and above all things by abstaining from eating too freely, especially of indigestible food when tired. Notwithstanding these facts most patients will never be entirely well after recovering from an attack of appendicitis, and if this is the case I believe that the best treatment consists in the removal of the diseased appendix."
    "In conclusion I will say that the most important lesson my experience has taught me is the fact that more harm is done to the patient suffering from acute appendicitis by the administration of any kind of nourishment or cathartics by mouth than in any other way, and that more lives can be saved by prohibiting this and by removing any food which may be in the stomach at the beginning of the attack by gastric ravage than by all the other methods of medical and surgical treatment combined. "

    [This is my belief and treatment and has been since I began to practice my profession.]

    The above extracts were taken from Dr. Ochsner's Monograph on Appendicitis.

    When a patient has completely recovered from appendicitis he should learn to live correctly. Learn to eat properly and to know how to take care of the body in every way.

    There is much to learn on the subject of what to eat, what not to eat, what foods to combine and what combinations to shun, when to eat, when not to eat, etc.

    Appendicitis is caused by wrong eating; those who go through the disease and recover, will have another attack unless they change their style of eating.

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