_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
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.
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
degree F., and 105.3 degree 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 degree 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 degree 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 degree 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 degree F.;"
[True, diffuse peritonitis set in at this time.]
"the symptoms increased in severity, and changed during the
collapse, his temperature 97.3 degree 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.