Treatment : Part 8

Appendicitis
by John Henry Tilden

(Page 13 of 18)

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.

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