Treatment : Part 1

Appendicitis
by John Henry Tilden

(Page 6 of 18)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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