APPENDICITIS- 7

CHAPTER VII

    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° 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° F., and 105.3° 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 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° 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° 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 suffered all the torments possible in this world of medical uncertainty. For fifteen years after starting to practice my profession I labored hard with symptoms of my own making. After drug action and symptoms were once developed, I knew nothing more about my patients; it is true I guessed, and theorized, and reasoned, but in truth I did not know positively just where my patients were. I consoled myself in those days with the thought that some day I should know; I believed that the fault was with me, that I was lacking in diagnostic ability, and that by hard work the time would come when I could read disease by its symptoms as well as the best, for I then thought the big men of the profession knew everything they pretended to know This was my ambition, but the ability to size up symptoms under given conditions and tell their true worth forever eluded me and kept me in a state of unrest and discontent that was next to ruining my life. If light had not come when it did I should have abandoned the profession, but it came accidentally; it could not come otherwise for I did not know how to look for it. In the course of time I stored in my memory many cases that from accident or caprice had recovered without drugs and food. The satisfactory advance made by sick people, suffering from different diseases, when they were left without food or drugs, occurred so often, and with such unvarying regularity that it ceased to be a coincident--it was absurd for me to continue to explain the results by the hackneyed word "coincident," a word that is usually loaded with a lot of dogmatism, idleness and selfishness.

    When I accepted the changes, taking place without medical aid, interruption and interference, as true cures, and so much a part of nature, and so intimately blended with the fixed laws of nature that like results could be looked for with the same degree of certainty that we look for the rising or setting of the sun, I busied myself in formulating a plan of cure as nearly in accordance with natural laws as I could. I am now, and have been for twenty years, developing in this line, and I have gone far enough to declare that I have watched symptoms start, mature, and decline, and in this way have learned, by contrasting the symptoms in a given ease that has not been medicated, with those of a similar case that has been medicated, to know the full value of symptoms under medication, as well as the full value of the symptoms when not under medication. This knowledge I am using in analyzing this medical classic and from my standpoint I can see how very easy it was for the author of the article under consideration to blunder along as he did. The doctor should not feel lonesome, however, for he has a world of company.]

    "This condition lasted nearly twenty-four hours; then a very large and hard stool, followed by a thin one of hemorrhagico-purulent character was discharged and simultaneously a decided change took place. The appearance and pulse improved; the abdomen became softer with the exception of the marked resistance upon the right side low down, and the fever slightly remittent, its maximum 101° F. Vomiting did not recur; the patient moved about somewhat in bed and slept several hours in a half-lateral posture. Meat jelly and cold beef tea were swallowed."
    [This feeding was the beginning of mistakes for the second round. If this patient had been left distressingly along until he could have thrown off his opium poison and become normal, and allowed the abscess to drain and close, all would have been well. This, I assume, would have been the ending if the vigorous examination that was given the patient the day before the collapse had not prematurely ruptured the abscess both into the gut and into the subperitoneal region converting an appendicular abscess into a perityphlitic one.]
    "Upon the next day there were several hemorrhagico-purulent stools, the urine was profuse and voided without pain. Nevertheless, firm, flat resistance was still felt in the lower right side and upon pressure there was lancinating pain no fever."
    [What was the need of this everlasting, eternal, never-ending manipulating to find how much induration there was? Nothing but harm could come from such senseless officiousness. The punching, feeling and manipulating of patients without a reasonable excuse is a very bad habit, one that is peculiar to young and inexperienced men. There is no reason, no object, no purpose in it; it is just a bad habit.]
    "There could be no doubt that the perityph abscess had ruptured into the intestine, and that in consequence of this the diffuse peritonitis had at once been relieved."
    [There was no peritonitis up to this time, except the small portion that represented the peritoneal covering of the organ or organs involved in the primary infection. The peritoneal cavity, or the peritoneum as an organ, was not involved in this disease; hence it is an error to say that there was diffuse peritonitis which was at once relieved by the rupturing of the abscess into the intestine. It is worth something to know the difference between a drug-created phantom peritonitis and a true peritonitis. It is not for the sake of controversy that I am taking exceptions to the opinions advanced in this case, neither is it because I delight in criticizing, differing from or finding fault with authority; I have a more laudable reason--one that I consider humane and justifiable--namely, to point out to the few who happen to read this book, a safe and life-preserving plan of treating one of the most talked about, and (because of bad--decidedly bad --treatment) one of the most fatal maladies of this age. To do this it is necessary to point out and teach these few how to reason on the subject, and how to weigh with something like exactness the various important symptoms that present themselves under varying styles of treatment.

    If a young physician is guided in his opinions by authority--if he believes that the last word has been said, because he has the last book from the leading authority, and if said authority has not yet learned that there is a true and a phantom diffuse peritonitis, said young man is not in line for saving life; on the contrary, he is liable to mismanage and meet with as great a failure, and be the cause of as unnecessary a death as was the good doctor from whom we are quoting and of whose medical sophistry I am trying to give the true qualitative and quantitative analysis.

    Rupture into the gut is exactly what will happen every time, in all cases, if left alone and no food nor drugs given.]

    "Treatment: Warm, followed by hot, flaxseed poultices; rest, freshly expressed meat juice or beef tea, in all 200 grams; thin gruel made with milk, 200 grams; wine, 100 grams in twenty- four hours, small portions to be taken every two hours; no drugs."
    [A little over six ounces of meat juice and six ounces of gruel made with milk! The starch contained in the gruel will always create gas in these cases and stimulate peristalsis; the gas inflates the cecum and drives the contents of the bowels into the abscess cavity; this sets up secondary inflammation. The meat juice and wine could have been left out to the patient's betterment. It is refreshing to know that no drugs were given, and if the case had been treated from the start on the no-drug plan the course and ending would have been very different. The poultices would have done as much good if they had been put on the leg of his bed, and much less harm.]
    "This improvement continued for several days and even became more marked The abdomen returned to the norm with the exception of the ileo-cecal region; there was a small stool daily without recognizable pus; no fever.
    "Upon the twelfth day of the disease vomiting suddenly recurred with severe diffuse abdominal pain, marked meteorism, and fever to about 102.2° F.;"

    [True, diffuse peritonitis set in at this time.]
"the symptoms increased in severity, and changed during the collapse, his temperature 97.3° F., pulse 160, thready, uneven; conspicuous facies hippocratica; no pain; a slight comatose condition, moderate meteorism, no movement of the bowels. Stimulants were without effect; subcutaneous saline infusion revived the patient but only for a short time? and death occurred the following morning upon the fourteenth day of the disease."
    [Meteorism! What at is it? A blown-up condition of tile bowels. Gruel caused gas to form the gas was driven into the abscess cavity, reinfection took place? which ended in diffuse peritonitis. The patient's resistance was used up and, being exhausted he died. He had made a brave fight a against all sorts of odds but the second round was too much for him.]
"Autopsy: Normal condition of the scrosa above the omentum: the appendix surrounded by adhesions embedded in fecal pus? gangrenous toward its terminal portion, and showing perforation; fecal calculus in the pus; appendix movable toward the cecum."
    [Just what may be expected in all cases! Nature is always busy reinforcing weak points, but the modern physician and surgeon is too wily and artful for her; she can't always anticipate his moves, hence she can't always fortify successfully.]
    "Agglutinated point of rupture at the median periphery of the cecum near the ileo-cecal valve. The perityphlitic pus appeared to be sacculated by adherent intestinal coils, but beyond the adhesions in the free abdominal cavity below the omentum there was diffuse, fresh, fibrinous peritonitis and distributed here and there small quantities of thin, putrid pus (many bacteria, large quantities of streptococci and cold bacilli). The peritoneum was injected. of a delicate rose-red color, here and there covered with fine, mucus-like pseudo-membranes. Heart flabby. "
    [The autopsy showed nothing more than would be expected. The fresh peritonitis confirms what I say that a reinfection was forced because of the character of the food. The meteorism opposed relaxation and rest, two conditions positively necessary and without which healing can not take place. What was to hinder the heart from being flabby, Drugs and systemic infection are quite enough.

    In proper hands this young man would not have been very sick; possibly his trouble would have been thrown off and the inflammation passed off by resolution.

    The following should be of interest for it is a very scientific explanation of how the young man came to die:]

    "The clinical history is in every respect typical and instructive.
    "It shows us that the origin of peritonitis which is by far the most common, is in a diseased appendix. At the autopsy this was found necrotic and perforated. It is questionable whether the perforation existed from the onset of the disease; it is possible that at first an ulcer extending to the serosa caused an infection of the peritoneum; at all events this occurred acutely, and produced the sharply defined disease."

    [I agree. The perforation brought on the relapse and the collapse.]
    "The clinical abdominal symptoms in the first period of the malady pointed to the fact that at the onset there had been a diffuse inflammation of the peritoneum, and that later, by the adhesions to the appendix which were found at the autopsy an early encapsulation of pus had taken place in the ileo-cecal region; this produced a purulent softening in the wall of the cecum and led to the favorable rupture of pus into the intestine and to an immediate amelioration of the acute peritonitis. The point of rupture, however, then closed, and partly perhaps to the action of fresh infectious and toxic material, perhaps only to the perforation of the appendix, may be ascribed the exacerbation of the peritonitis, that is, a renewed attack which caused the death of the patient."
    [The symptoms were those of intestinal putrefaction with local inflammation of the cecum and, as the history of the ease has pointed out, was located in that part of the cecum giving attachment to the appendix, for the autopsy showed that the appendix was surrounded by adhesions and imbedded in fecal pus. Please note particularly: The appendix was found in a pus cavity--a perityphlitic abscess. Why shouldn't the appendix be necrosed? Located in a field of inflammation, blown up, distended beyond its vital integrity; why should it not become gangrenous, It doesn't matter when the perforation of the appendix took place for it is quite evident that there was not enough disease of the appendix to cause its perforation until after it had become encased in the abscess cavity, and if the young man could have been freed from the treatment he received and could have been given the necessary rest the abscess cavity would have emptied itself, necrosed appendix and all, into the bowel and he would have made a perfect recovery.

    "The point of rupture closed!" How could a rupture into a distended gut close, The distention was greater after the rupture than before. Fresh infection could not take place without a power to force the putrefaction greater than the force that existed before the abscess broke into the cecum. Let us reason together: Nature fought successfully against heavy odds before the rupture. There was gas distention of bowels interfering by pressure with the circulation and increasing the area of destruction of tissue; frequent retching and vomiting interfering by stretching and probably tearing, threatening disruption to the plastic process that was going on to close in the disorganizing and necrosing processes; the frequent examinations, and manipulations for diagnostic purposes, etc., but, in spite of all this opposition, fatal infection was successfully resisted; then, after the rupture and discharge, the relaxation, the calling off by nature of all her defenses, showed that the battle was won. All the defense yet left was the hard induration, "firm, flat resistance." This induration was quite sufficient to prevent reinfection, had there not been something out of the regular order to interfere. In this case there was a prostrated muscular system. The narcotic had left the patient without muscular power. The starchy food created gas, and the bowels, not having their natural tone, gave way to the gas until there was "Meteorism," not tympanites but meteorism which means to blow up or distend all that is possible.

    Such a state as that means mechanical interference with every organ in the thoracic, abdominal and pelvic cavities, and, besides the pressure and interference in drainage and the blowing into the abscess cavity and into the pyogenic membrane gas loaded with infection, there was an almost fatal interference with the action of the heart and lungs. The prostrating effect on the muscular system of the septic or putrefactive poison was nothing to be compared to the paralyzing effect of opium. I believe this man would have survived every interference if the milk gruel had been left out, but acting as it did, it proved to be the last straw.]

    "In regard to the fulminant symptoms at the onset of the disease, however, it is more likely that even then perforation had already occurred, and I that the final and fatal exacerbation was in consequence of adhesions formed in the first period which were powerless to resist the entrance of organisms producing inflammation. The pus finally broke through the adhesions, and produced diffuse peritonitis."
    [It is a technical point unnecessary to raise whether the adhesions formed in the first or the last period; they were formed without question; I and if they were formed in the beginning, as doubtless they were, they withstood the most severe and trying period of their existence, which was before the abscess broke into the bowels, and so far as being able to resist to the very last, there has been no evidence to prove that the last infection was because of any lack of power of resistance on their part for the autopsy showed them intact. It is doubtful if anything but sound tissue could have withstood the strain that was put upon this man's diseased cecum from gas distention. The infection-laden gas could find a way anywhere in diseased tissue and broken continuity. Why should the pus break through the adhesions and find its way into the peritoneum after they had been able to make an effectual resistance till the bulk of it had forced a passage into the bowel? Why should the adhesions have less power to resist when there is less strain upon them and also a patent outlet for the pus? I fear our German friend of "Die Deutsche Klinik" had "booze" in his logic when he was explaining how his patient came to die.]
    "Moreover, the bacterial finding of streptococci and cold bacilli in the perityphlitic abscess is typical, and the limitation of the diffuse peritonitis to areas below the omentum is also instructive. This simultaneously prevented the invasion of organisms producing inflammation into the serous surfaces above."
    [There is nothing strange about this for nature works for the purpose of preventing " serous surface" invasion, and it takes a deal of malpractice to force such an infection. If nature's provisions against peritoneal inflammation were not as great as they are, few people with intestinal putrefactive diseases, from cholera infantum in babyhood to proctitis in old age, would get well, for most of the treatment for one and all of these diseases is obstructive rather than conservative and helpful.]
    "This strong man, aged 31, had previously regarded himself as perfectly well. Nothing indicated the danger in which he found himself and which had existed since the appearance of the fecal calculus. the time when this had formed being impossible to determine. The disease appeared acutely with fulminant symptoms."
    [He was, indeed, unfortunate, but his greatest misfortune, as I see it, was his treatment. Every acute disease is fulminant, even indigestion is fulminant, but the force of the warring elements is soon expended and unless reinforced by fresh elements the fulmination must end.

    In diseases such as typhoid fever, appendicitis and typhlitis, we have first of all a constitutional derangement brought on by errors of life. The general resistance is lowered from nerve-exhausting habits; the general tone of digestion is below par and the bowel contents are maintaining a higher toxic state than usual; we have added to this condition an unusual tax in a long run of hot weather, business worries or unusual mental, physical or digestive strain, following which acute intestinal indigestion manifests with a sudden explosion; or there takes place a transformation of the contents of the bowels into an intense putrefaction which infects a portion of the mucosa that has been rendered susceptible by pressure from fecal impaction, concretions, or any cause capable of devitalizing. If the infection takes place in Peyer's patches, typhoid fever is the consequence; if the local trouble is of the cecum, typhlitis will result, and if the local devitalization is in the appendix, brought on from the irritating effects of a fecal calculus, appendicitis will result.

    These diseases may start in a fulminant manner as suggested--with an acute intestinal indigestion, which will die down as soon as all the elements that combine to set off this fulmination l eve expended their force and unless fresh material be added everything must settle down to a local trouble. Or if the primary irritation is subjected to a light form of toxic infection the development of the disease will be much more insidious and will require much more time to come to its maturity, or its fulminating stage.

    The reason for this is that each person has a cultivated immunity to a given toxic state of the intestinal contents, and when from pressure or the irritation caused by a calculus. there is a denudation of the mucosa the infection that takes place has not the power to arouse a systemic resistance' but can cause only a local inflammation; this inflammation may end in ulceration, or it may cause a thickening of the parts and interfere with drainage from mucous or glandular pockets; then the locked up secretions become intensely toxic, and this sets up a new infection much greater then l the first and powerful enough to cause the system to call out its militia to put down the rebellion. Now we have fulmination, but if food and drugs are withheld it ends soon.]

    "Severe abdominal pain with tense abdominal walls, fever and vomiting form the characteristic triad in the first phase of the disease; less rapidly does meteorism appear. This depends upon whether the inflammation of the serosa quickly spreads or remains local. Peritoneal meteorism is peculiar. The abdomen is uniformly distended, balloon-like; the muscles as well as the rest of the abdominal walls are tense. It must be added, how ever, that in spite of the excruciating pain upon touch there is no sign of contraction of the abdominal muscles, of the "muscular resistance" (defense musculaire) which is so common on pressure in other forms of abdominal pain, particularly when circumscribed."
    [Distention from any cause--or stretching of muscular fiber--causes paralysis for the time being.]
    "The same is true of the diaphragm; it is forced upward, the muscles are therefore elongated and tense; but there is no evidence of active contractions. Abdominal respiration ceases; gradually then, as may be recognized by the limits of percussion, increasing loss of muscle tonus is added. In this case the autopsy showed that the peritonitis had not advanced up to the serosa of the diaphragm."
    [The muscle tonus when a patient is under the influence of opiates cannot be reckoned with, for that drug paralyzes the muscles, and the bowels fill with gas as was seen in this case up to the day before the abscess ruptured; on that day feeding had been suspended, resulting in a decrease of gas and an amelioration of all the symptoms.]
    "Among these signs pain, either spontaneous or upon touch, a rise in temperature, increased frequency of the pulse and, in general, the signs of severe illness, are to be looked upon as the local and general symptoms of a severe septic inflammation; vomiting, at least in the first stages of peritonitis, was due to decided reflex irritation of the numerous branches of the peritoneal nerves; the fecal discharges at the onset may be explained, but by no means invariably, as due to peristalsis acting reflexively. The constipation which followed this, however, as well as the meteorism, must be attributed to a hypotonia and paralysis of the musculature of the intestine by collateral edema."
    [Beautiful sophistry. Words well woven together are captivating and frequently dethrone reason. If I didn't happen to know better I might really believe the author of this contribution to medical science knew exactly what he was talking about.

    The constipation in such diseases as this is caused by the fixing, or natural resistance to motion, which is always to be found in diseases of tile bowels and is one of nature's conservative measures. The hypotonia or paralysis of the musculature was brought about by the opium; and it is certainly strange that educated men can build a symptom or condition by the administration of drugs and yet remain absolutely unconscious of the part they are playing, and proceed to build a beautiful theory explanatory of results.]

    "The excessive abdominal pain, increased by movement and on the slightest pressure, caused the patient to remain motionless upon his back and to avoid the slightest movement of the abdomen either by speaking or coughing."
    [This is a characteristic symptom when there is great distention of the bowels.]
    "At the start the temperature was uniformly high, but later remissions in the pus fever were recognized."
    [All fever would have disappeared had it not been that the intestinal putrefaction was kept alive by feeding.]
    "The pulse from the onset was comparatively frequent, regular and somewhat tense.
    "The vomitus was at first composed of the gastric contents, the bile of a peculiarly pure, grass- green, biliverdin color mixed with a yellowish chyme-like material, and in the later stages of the disease showed thin masses having a fecal odor (ileus paralyticus). In regard to the dejecta, the two passages at the onset of the disease pointed to increased peristalsis; this was of short duration, soon changing to the opposite condition, and until the rupture of the perityphlitic abscess absolute constipation existed."

    [The vomiting would have gone to stay within three days if no drugs nor food had been given; as it was, when real vomiting ceased the opium nausea began.

    This patient was not allowed to come into that state of peristaltic elimination that is due in all cases in three days at the farthest, and which would have come to this man if food and drugs had been withheld.]

    "Pain upon urination and strangury was due to inflammation of the peritoneal coat of the bladder, in which a noticeable irritation was produced by slight distention as well as by contraction of the bladder. The albuminuria was the well known infectio-toxic 'febrile' form; indicanuria was in proportion to tile fecal stasis.
    "In the course of the next few days a new symptom was added to this group: Exudation, which was demonstrable both by palpation and percussion. It was the natural consequence of inflammation of the peritoneum, and was both of diagnostic value as indicating general peritonitis and of special value in that, more definitely than the pain, it pointed to the original seat of the affection, which, according to present indications, could only have been an internal incarceration following right-sided inguinal hernia, or femoral hernia, or appendicitis. As neither the history nor the general status (normal condition of the hernial rings) furnished any points of support for the first view, only the diagnosis of appendicitis, that is, of perforation of the appendix, could be made with that degree of certainty attainable in diseases of the abdominal cavity in general.
    "After the appearance of these symptoms, a more or less firmly adherent but limited perityphlitic abscess, and a less intense although well developed peritonitis in this region, were assumed; the latter, notwithstanding the painful meteorism, was not necessarily diffuse in the strict sense of the term; the omentum often protects the upper abdominal cavity from infection, as was proven in this case at the autopsy. It is possible that this diffuse peritonitis, which did not in the early period of the affection extend beyond the limited local focus, was not due to the intestinal contents and to bacteria, but chiefly to bacterial toxins which arose from the circumscribed original focus. This fact is pointed out by the prompt retrogression of the diffuse peritoneal symptoms after rupture of the abscess; the diffuse peritonitis of this stage might then be designated a nonbacterial 'chemical' inflammation, according to the terminology now in vogue; finally, it was positively a bacterial infection, although the postmortem finding of bacteria in the distant folds of the peritoneum is not proof of this; we know that during the terminal agony or after death these may wander a long distance from the perityphlitic focus."

    [The author plays so fast and loose with the words, "diffuse peritonitis," that I am reminded of a remark made to me several years ago by a society lady who posed as a pace-setter in all matters pertaining to the intricacies of what one should and should not do. The subject was one that I did not know much about at that time, and upon which I am not much better informed at present. It was on diamonds. I complimented her on a very beautiful sunburst. She took the compliment modestly, of course. The center diamond was large and, I thought, of uncommon brilliancy, and I remarked, "That center stone properly mounted would make a very fine solitaire." She then informed me that she once owned a cluster of solitares.

    The author tells us that at first the diffuse peritonitis probably did not extend beyond the local focus; this of course is exactly what I am contending for from first to last and I insist that there was not peritonitis proper until the occurrence of the fatal relapse.

    It is somewhat surprising that this article should be selected to represent the last word on this subject, when the author builds his treatment upon diffuse peritonitis; then enters into a lengthy analysis and explanation of symptoms to fit the diagnosis and treatment and before he is through with the subject he declares that the diffusion is confined to the focus of infection.

    If I did not know something of the worth of words I am not sure but such an excellent explanation might persuade me!! If I did not know from experience that all this is theory, beautiful theory, it might be very hard to resist!]

    " After the symptoms of local and general inflammation with their secondary signs in the stomach and intestine had lasted for six days, suddenly a complete change took place: The nervous, anxious, extremely distressed patient became feeble and scarcely complained at all; his formerly congested face was pale and elongated, the nose pointed and cool; the skin lost its turgescence and warmth and was covered with a cold sweat; the bodily temperature also fell, the pulse became small and frequent but remained quite regular, the abdomen became softer and to a great extent lost its sensitiveness; the vomiting decreased to a few painless attacks,"
    [wholly due to the opium and morphine given]
    "and singultus disappeared: A picture which, to a certain extent, is a combination of collapse and narcosis although not to the degree of profound loss of consciousness, being the picture of an intoxication in sharp contrast to the preceding febrile state."
    [That is exactly what I stated above--a case of narcotism. How is it possible that the author, recognizing the narcotism, feels it incumbent to give other explanations?]
    "Just as the affection had suddenly developed to its full height at the onset of the disease, and much more swiftly than, for example, is the case in phlegmon of the external walls, so with extraordinary rapidity did the clinical picture assume a new type. In this respect we must consider the very great area of the peritoneal folds, their numerous lymphstomata, and their intimate relation to the circulation, and we are impressed with the fact that fluids and solubles, as well as formed products, are rapidly absorbed by the peritoneum.
    "Somewhat less rapidly than this, but nevertheless in the course of a few hours, another change took place, a favorable turn following the rupture of pus into the intestine. Here we were dealing with a well known and familiar phenomenon; if this occurs in the peritoneum the effects are particularly well marked; similarly as in the case of a phlegmon which rapidly disappears with the discharge of pus even although the inflammation extend beyond the pus focus, the symptoms of diffuse peritonitis promptly disappeared after the rupture. Very likely, as has already been stated, the symptoms of diffuse peritonitis in the first stages of the disease are to be referred to a chemical inflammation of the serosa, i. e., one due to toxins and without the ingress of bacteria; and it must be remembered that the clinical picture of this chemical peritonitis cannot be differentiated from that of the severe bacterial form. With the rupture of the abscess, the entrance of poisons into the free peritoneal cavity, and their resorption by the extensive peritoneal surfaces, as well as the vomiting and the intestinal paralysis, ceased. The taking of nourishment again be came possible.
    "The point of rupture formed adhesions, the natural drainage of the peritoneal ichorous focus ceased, perhaps a new influx of inflammatory material from the perforated appendix also took ; place. There was a fresh relapse of the local peritonitis which extended beyond the boundaries of the limiting adhesions, and permitted the invasion by bacteria of the free abdominal cavity. This , time the severe toxic picture of collapse immediately followed, and with marked decrease in cardiac strength led to death.
    "Doubtless the patient might have been saved in the first stages of the disease by the evacuation of the abscess; the incision would at first have acted similarly to spontaneous rupture into the intestine, but the relapse would have been prevented by permanent drainage, and a radical cure might have been brought about by the immediate or subsequent removal of the appendix.
    "Opium, no doubt, had a favorable effect upon the affection. By relieving intestinal irritability, and by bringing about a mild degree of narcosis, the patient was kept quiet and this materially assisted in limiting the severe perityphlitic suppuration in the first stage of the disease."

    [All of which is positively not true, as I have witnessed for years.]
    "If, as it unfortunately happened, the point of rupture had not immediately closed again, if it had remained open until suppuration ceased and contraction and healing of the perforated appendix had taken place, opium would have been regarded as instrumental in saving the patient, and unquestionably, at least to some extent, justly so. Among other factors in the treatment, the relief to the intestine by the suspension of nourishment was of paramount importance. The subcutaneous saline infusion had an obvious but, naturally, only a transitory effect.
    The subcutaneous saline infusion is another ridiculous habit. It would really be amusing if it were not so tragic, to see patients driven to the edge of the great divide and then see the innocent doctor throw out an impotent life line.

    The absolute innocence displayed by this professional man, from first to last, his belief in himself and the mechanism of his theory and practice exculpate him from the charge of carelessness, neglect of duty or even that he didn't know what he is doing. He does know what he is doing in a way. He works as exactly as a Waltham watch and he thinks about as much as the stem that winds the watch.

    I cannot agree to the summing up of this case. There was not at any time, previous to the relapse and death of this patient, what we understand as peritonitis. A post-mortem examination might have shown the intra-peritoneal covering, of that portion of the cecum involved in the inflammation, slightly inflamed, but it is not reasonable to believe that the inflammation was of a toxic character unless adhesive inflammations can be so called.

    Inflammation is always the same, it matters not what the exciting cause may be. It is an exaggerated physiological process. If there is inflammation of any part of the body it means that there is an exaggeration of function. Its intensity will be in keeping with the exciting cause. If the cause is intense heat or cold, or a corroding acid or alkali, the local action may be great enough to destroy the part; the inflammation following will be of the contiguous structure outside of the killing range of the cause, and it will be a simple--non-toxic--inflammation unless the secretions thrown out in excess of the reparative need are retained by dressings or prevented in some other way from draining away. If these secretions are kept bound on the raw surface by dressings until they decompose--yes, until the fermentation causes germs--the wound will become infected, and to what extent will depend upon the amount of malpractice--carelessness or ignorance--to which the case is subjected.

    If the inflammation is caused by decomposition or a toxic agent, the extent of the process will depend upon the integrity of the part infected and the state of the general health, also upon the local environment--such as pressure interfering with the circulation of the blood.

    In this fatal case there was the constitutional derangement and the toxic state of the alimentary canal; then there was the exciting cause, sufficient to create a local infection the symptoms of which were given at the beginning of this description, and which lasted for a few days; during which time the patient, no doubt, was eating and possibly taking home remedies to move the bowels, etc. These preliminary symptoms were followed by a severe pain in the right lower abdominal region, followed with chills, fever, nausea, vomiting and later by painful movements from the bowels, small in character, and soon after this distention of the bowels from gas.

    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 nature's 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 abdomen--the bowels and all involved and contiguous parts-- became 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 "about midday; he was seized with very severe pain." 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 can't 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 "Acute, Diffuse Peritonitis." 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 doesn't 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 fingered--thumbed 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. 

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