APPENDICITIS- 8

CHAPTER VIII

    The following case comes to my mind, for some of the initial symptoms are similar to those of the case just described: M. B., age 42, farmer, was taken sick with the usual symptoms of appendicitis as near as I could get the history from his wife, who was his nurse. He lived twenty miles from Denver. When he was taken sick he called a local physician who treated him for bilious diarrhea. The drugs used, as near as the wife could remember, were small doses of calomel followed with salts to correct the I liver, morphine for pain, and bismuth and pepsin for digestion and diarrhea, and quinine to break the fever; also hot applications on the bowels.

     The pain was so great that morphine had been given quite freely. At the end of one week the sick man, being no better, declared that he would go to Denver and consult another physician. When he told his physician what his intentions were, the doctor advised him not to attempt the trip himself, for he was too sick, but to send for the physician. The sick man was willful and forceful, and he was also afraid of the cost; and, being a plucky fellow, he declared that he could go just as well as not and that he would and he did.

    His wife was a large, strong woman and gave him valuable assistance, but I never have understood how it was possible for so sick a man to make the journey from his home to my office. He was obliged to help himself a great deal in climbing in and out of ordinary conveyances to reach the train and, when in Denver, with his wife's assistance, he walked a half block to the street car; then from the car to my office he was obliged to walk one block and at last climb one flight of stairs. When they came into my office the wife was almost carrying him. I saw at a glance that he was a desperately sick man, and before I attempted to examine him I had him lie down for a while.

    He had no history of any previous sickness; he had always been very healthy, and his life had been spent in hard work in the open air.

    The general appearance of the man was that of one suffering from diffuse peritonitis. The abdomen was enormously distended; this symptom more than any other caused me to fear and wonder--fear that rupture would take place before he could be put to bed, and wonder how it was possible for a man to be out of bed and go through what he had gone through that morning without causing a fatal injury of some kind. The distention, I was informed, had been gradually coming on from the first, and he had been given morphine to control the pain from the first day of his illness. When they gave me this information I knew that the tympanites was due to narcotic paralysis, instead of coming from perforative, septic peritonitis, as the general appearance and symptoms indicated. This reasoning gave me hope in spite of the formidable appearance of the case.

    The pulse was 130, temperature 102° F., in the forenoon; he had been troubled with nausea a great deal, but with the exception of one or two vomiting spells, the first and second day, the nausea did not often cause retching. The mouth and lips were dry, tongue coated, bad taste in mouth and breath very offensive.

    The reason there had not been more vomiting in this case was because there was diarrhea at first and not quite so much locked up fecal matter as common. The bowels had been relieved of the usual accumulation more than is common to the majority of such diseases before the swelling and fixation had become established.

    There is a small percentage of people who are not quite so irritable as others; in these the contraction, constriction or fixation--the embargo laid on these parts by nature in her conservative effort at preventing movement--is not established quite so early, and the efforts on the part of doctors to force a movement are more successful in cleaning out a part of the accumulation; or there may come a diarrhea from the putrefactive poisoning which is causing the infection of the cecum or appendix and leading to abscess, and this causes a partial cleaning out before fixation is established; in these cases there is never so much vomiting nor nausea, neither do they suffer so much pain for there is not the usual accumulation in the alimentary canal to excite the peristaltic movement.

    The history that the patient and his wife gave me from memory was that the urine had been scant, and at times painful to pass. There had been from the start severe pain in the lower bowels, but neither the patient nor his wife could remember if there had been more pain on right, lower frontal region than anywhere else; they both declared that the pain was all through the bowels and that there was much bearing down like unto the pain of a diarrhea.

    Breathing was shallow, of course; it never is otherwise in severe abdominal distention.

    I scarcely touched the abdomen, for I knew I dare not press, in percussing, enough to distinguish any sound except the tympanitic. It has never been my custom to allow my curiosity to run away with my judgment, and cause me to make needless examinations.

    All examinations are needless when, it matters not what the diagnosis can or must be, the treatment will be the same. All possible bowel troubles which present the same general symptoms of the disease I am here describing, must receive a like general treatment. This being true, it matters not what the difference is, there cannot be a variation requiring a bimanual examination to differentiate it that will justify the risk. All examinations are needless and criminal when there is a possibility of rupturing an abscess. Especially is this true when it is a positive fact that all typhlitic and appendicular abscesses will open into the bowels if allowed to do so.

    In this ease I reasoned as follows: This must be a case of abscess, for the signs of obstruction are not those of complete obstruction, such as are seen in hernias, volvulus, constricting bands and many other causes not necessary to mention. If there were complete obstruction there would be increasing nausea and vomiting, ending in collapse and death. This tympanites cannot be from peritonitis for perforation would be necessary to cause it and nothing would stop the progress after it had once started except to open the cavity wash and drain. Hence this cannot be peritonitis, for there has been no operation and the patient still lives. It can be distention from the effects of morphine, but there must be more than morphine paralysis, for there is a temperature of 102° to 103° F., and there has been, so the wife says, a temperature of 104° F. The pulse rate being 130 does not indicate fever nor exhaustion, and is not in keeping with the temperature nor physical strength, hence the rapidity must be partly due to pressure on the diaphragm from the gas distention and partly from the paralyzing effect that opium has on the heart.

    The professional reader will see that I have by my analysis eliminated much of the formidableness that the physical appearance gives to this case, but I would not have you believe that this man was not a desperately sick man even if I have accounted for the dangerous symptoms. The fact is, if the pronounced symptoms had been what they appeared to be, the man would have been saved his trip to me, for he would have been dead.

    The farmer had learned from experience that the less he put in his stomach the better he felt; hence, for a day or two before he left his home to consult me, he had refused food and drugs and had taken very little water.

    After giving the sick man a rest in my office I had his wife take him to the home of a friend with whom they had arranged to stay while in the city. In a few hours I visited him and made the following prescriptions and proscriptions: Positively no food, not one teaspoonful of anything except water. An enema of half a gallon of tepid water to be used once each day for the purpose of clearing out the bowels below the constriction, and I advised against violence--rough handling. A hot water jug to the feet, fee to the abdomen, all the fresh air possible in his bedroom and absolute quiet. If nauseated, enough water to control thirst was to be used by enema; if the stomach was all right all the water desired by mouth.

    I called the second day; the patient had slept some--he thought about three hours of broken rest--feeling fairly comfortable; pulse 120, temperature 101° F. at 9:00 a.m.; 102° F. at 5:00 p. m. Third day: Temperature 100° F. at 9:00 a. m.; 101° F. at 5:00 p. m.; one-third of the tympanites gone; slept six hours; hungry and demanding food. I said, "No, you get no food until the bowels move." The ice was taken off the bowels; hot cloths were substituted.

    The fourth day the temperature in the morning was 100° F.; in the afternoon 101° F., pulse 100; slept well, hungry, bowel distention reduced fifty per cent. I touched him very lightly and found enough to confirm my diagnosis of typhlitic abscess; this was the first time I had felt that I was justified in attempting to confirm my suspicions, and even this examination could not be called a palpation, for I put no weight upon the abdomen. The patient was very dissatisfied because I would not allow him food. I said, "No. you can't eat until your bowels move." "How soon will they move!"" he asked in an irritating and ungracious manner, to which I replied, "Your God only knows, and He won't tell."

    Fifth day about the same, a little better; very ugly because I would not allow him food. He said: "I don't believe there is anything the matter with me; you are holding me down."

    Sixth day about the same, feeling fine, sleeping fine and starving to death. He made himself so unpleasant by his clamoring for food that I permitted his wife to give him a half dozen Tokay grapes. He had scarcely swallowed the sixth when he had all the pain he wanted. His wife came to my office in great excitement: "Doctor, please come at once to see my husband; he is much worse, he is in agony with his bowels. " My answer was: "Go back and renew your hot applications to the bowels and tell your husband I permitted him to eat the grapes because he had been so unkind and ungrateful for the comfort that had been given him; tell him that I knew the grapes would give him pain and that the pain will not wear off entirely for twelve hours, and that I will not see him before tomorrow morning."

    I called as I agreed to do the next day, the seventh day since the case came under my management, and the fourteenth day from the beginning of the disease. The sick man was out of humor. To my question, "Would you like something to eat!" he drawled, "Na-a-aw! I never intend to eat any more; but I would like to know when my bowels are going to move." Of course I could not tell him any more than I had told him before, namely, that under such circumstances they usually require from fourteen to twenty-eight days.

    From this time on every day was much the same; no elevation in temperature, and the pulse ranged from eighty to occasionally one hundred; no pain, sleep good, that is, as good as people generally sleep who are on a continuous fast--under a continuous fast the sleep is good but not heavy nor long at a time.

    It is a fact that when these cases are properly handled they are not sick after the first week; they do not look sick; they get to thinking that it is folly to stay in bed and live without food, and of course their neighbors know that there isn't anything the matter with them; that the doctor is starving them to death. Quite a number of my patients have brought themselves near death's door from disobeying instructions and taking the advice of knowing neighbors. They were persuaded to ""eat"--"eat all you want, for the doctor will not know it."

    This is one disease that will give the disloyalty of the patient away every time.

    On the morning of the nineteenth day of his sickness, and the twelfth day of my services, I called to see the sick man, and before I could ask him a question he shot out his hand toward me and exclaimed, "My bowels moved at four o'clock this morning! I want a beefsteak for my breakfast!" I congratulated him on his fine condition and ordered him a dish of mutton broth. This disgusted him thoroughly, and his reply was in kind: "A dish of broth! After fasting two days on my own prescription, and then twelve days on yours, I am to be rewarded with a dish of broth." I explained that he had a large abscess cavity that would require several days to empty, collapse and draw together, and if he should eat solid foods too soon he would run the risk of cultivating chronic appendicitis--recurring appendicitis. I advised him to live on liquid foods for three or four days, and after that he could have solid foods if he would practice thorough mastication.

    The action from the bowels had been saved for me; there was an ordinary chamber half full; it looked to me like at least a half gallon of fecal matter, pus and blood; it was dreadfully offensive. Six hours after the first movement I was informed that he had another movement very similar in quantity and consistency; this movement I did not see, for I did not visit the man after the morning of the nineteenth. He left for his home on the morning of the twenty-third and has had excellent health ever since.

    If this man had been subjected to daily examinations food and drugs, would he have presented the same symptoms! Indeed the tympanites alone would have killed him. Was his case diffuse peritonitis? No! For if there had been intra-peritoneal infection in the first place, it would have indicated perforation, and then, without the opening up of the peritoneal cavity, washing and draining, there would have been a funeral.

    The following is a similar case except that the woman came into my hands the first day of her sickness. Her symptoms were: Nausea, vomiting and pain all over the bowels as she said--as much pain in one place as another--temperature 102° F., which ran up to 103° F. in the p. m.; pulse 110, and a history of constipation. She had several movements from the bowels through the night before I was called in the morning. The movements were small and accompanied with much griping; the patient said that if she could have a good cleaning out of the bowels she felt that she would be well. I informed her that she had appendicitis and that she would be compelled to remain very quiet in bed, with ice applied locally until the temperature was reduced to 101° F., or less, and then substitute hot applications. For the pain I had her stay in the hot bath until relieved, and when the pain returned she was to go to the bath again. The bath water was ordered to be used as hot as possible. Every night an enema of warm water. The treatment did not vary from the farmer's and the results were the same--her bowels moved on the nineteenth day; the consistency and amount were about the same, and I had her exercise care about her eating for a week after the abscess discharged. From the end of the first week of her sickness until the abscess broke she expressed herself freely that she did not believe there was anything the matter, and that going without food when one felt well was foolish; however, she obeyed and had no suffering.

    A son of the woman whose case I have reported above was taken down the same way one year after. I explained the situation and told the young man that he must keep quiet and go without food just as his mother did the year before. I did not think it necessary to visit him very often, for he knew how his mother was treated, besides she was with him to advise.

    Within three days he was comfortable, and remained so until about the seventh or eighth day, when he decided he would take a glass of milk and not say anything to me about it. He took the milk and was writhing in pain within two hours. I was sent for, and of course asked what he had eaten, whereupon he told me that he had taken milk. Within twenty-four hours he was easy and cured of his desire to eat until ready for it. This case terminated by rupture of the abscess on the fifteenth day.

    Neither of these cases had any tympanites worth mentioning. All cases that I have ever seen with great bowel distention are those coming into my care after being subjected to the usual feeding and medicating.

    Now we will go over Dr. Vierordt's case in connection with mine and see if his case of diffuse peritonitis is not about as near like my case as it is possible to have two cases.

    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° 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° 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° 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. 

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