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Appendicitis: The Etiology, Hygenic and Dietetic Treatment by John H. Tilden, M.D.

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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

"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

[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

"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

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

"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

"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

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

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.


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

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 degree 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 degree to 103 degree
F., and there has been, so the wife says, a temperature of 104
degree 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

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 degree F. at 9:00 a.m.; 102 degree F. at 5:00
p. m. Third day: Temperature 100 degree F. at 9:00 a. m.; 101 degree
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

The fourth day the temperature in the morning was 100 degree F.; in
the afternoon 101 degree 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 degree F., which ran up to 103
degree 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 degree 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

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 degree
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 degree 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 degree 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

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.


_I have appendicitis; what shall I do to be saved? _Don't eat
anything until well. Use a stomach tube and wash out the stomach;
then use a fountain syringe and wash out the bowels; take a hot bath
as hot as can be borne, and stay in the tub until all the pain is
gone, or as long as possible; then go to bed, put ice on the bowels
and keep it on until the temperature is reduced to 101 degree F.,
then apply hot applications or poultices and continue the poulticing
until the bowels move, and the bowels will not move until the
abscess breaks.

Use an enema every night as a routine, and drink all the water
desired, when there is no nausea.

Don't manipulate the forming abscess, nor allow anyone else to do

If you are really in doubt about what you have, think over what I
have written about strangulation or positive obstruction, and if you
think you have it, send for the best physician you know and get his
opinion of whether you have obstruction or not, but don't allow him
to burst an abscess with his manipulations! For, my word for it, if
he can't weigh symptoms and tell whether or not you have complete
obstruction without punching holes in you with his bimanual
manipulation, neither would he be able to do so after examining you.

I do not say this because I like to make it hard for doctors, but I
prefer staying the heavy hand of the doctor to keeping still and
allowing him unwittingly to kill his patient.

First of all wash the stomach out with a siphon tube, then see to it
that nothing but water goes into the stomach until the bowels move.

I put my cases on a complete fast, give no drugs, apply ice to the
region of the appendix, keep the feet warm, and keep the patient in
an atmosphere of hope and belief in his recovery, and a recovery
always follows. I prescribe an enema of warm water once or twice
daily, getting all the water possible into the bowels.

These patients are so comfortable after the second or third day that
it is hard to make them or their friends believe that they have
appendicitis People are so afraid that they will starve to death if
they have no food for a few days that they make haste to get put on
a killing treatment rather than run any risk. This fear is absurd
Physicians are largely to blame for this popular ear, for those who
do not feed by mouth still have the idea that their patients must
have nourishment, so they feed by rectum. This is also absurd. What
the patient needs is rest, and the more complete the rest the
quicker the recovery. Give the patient all the water he wants.

The bowels will move in fourteen to twenty eight days from the
beginning of the attack. Then the fast can be broken by giving a
glass of hot milk, which is to be chewed well, or given in the form
of junket; this is to be repeated three times a day for a week, or
give the milk twice a day and a plate of mutton broth for the third
meal. I do not give solid food because there is a large abscess
cavity opening into the bowels, and if solid food is given before it
has time to close, it is liable to find its way into this cavity,
thereby preventing healing, and bringing on a chronic condition that
will ultimately end in death. The less food taken for one week after
the discharge takes place, the better. Any rational individual
should see that withholding food is the proper treatment. Milk
should be thoroughly mixed with saliva or not taken at all. Remember
that if milk is not taken with great deliberation, and great care
given to _thoroughly insalivate each sip, then it amounts to the
same thing as eating solid food._

Milk is a solid food when taken into the stomach as a beverage or a
drink like water.

In appendicitis all nature cries out for rest, and if it is given 99
out of every 100 cases will get well and there will be no suffering
and no danger after the first seventy-two hours.

The ordinary physician sends for a surgeon, and if he is a victim of
the surgical mania the patient must be operated upon at once, for if
twelve or twenty-four hours are given, the conditions may clear up
and an operation will be unnecessary. The majority of surgeons feel
that they will forfeit their right to heaven if they do not cut at
once. The consequence is that there are many patients operated upon
who are as innocent of having the disease as the surgeon is innocent
of a knowledge of a better plan of treatment.

Of course, the surgeon declares that pus should be let out by
cutting into it, or it is liable to break into the peritoneal cavity
and cause death This is positively not the truth, for when an
abscess threatens, nature at once proceeds to throw a wall around in
order to avoid accidents. All around the point of prospective
abscesses, heavy walls of adhesions are built, and if nature is not
interfered with, the abscess will break into the gut, because it is
the point of least resistance, and it is also the point favored by
gravity. The surgeons when they operate in these cases work exactly
opposite to nature.

If these abscesses are allowed to open into the bowel and solid food
is kept away from the patient, full and uncomplicated recovery will
take place. If solid food is given too soon it is liable to find its
way into the abscess cavity and cause a blind fistula, which may
take on acute inflammation at any time. These cases then become
chronic and are called recurring appendicitis. It is sound surgery,
in dealing with abscesses, to find, if possible, the direction
nature is taking to evacuate pus and be guided by this suggestion in
evacuating a pus cavity.

In order to cure appendicitis you must remove the cause. Cutting off
the appendix, opening an abscess, withholding food till the acute
symptoms have passed; such treatment is not removing the cause.
Nothing short of changing the eating habits of the patient will
cure, so the surgeon who knows nothing about food and its
action--what part improper eating has to do with bringing on the
disease--will never be able to cure.

Operating for this disease will fall into disrepute in time, for
there are already cases recurring and the second and third operation
will be necessary among those who survived the first. There is not a
scintilla of logical reasoning in defense of the operation. Because
some get well after an operation is no proof that the operation was
necessary; fortunately for the operator there is no way to prove
that the case operated upon would have recovered without the
operation. If the case be not complicated by bungling treatment an
operation is uncalled for. If a case has been medicated and fed to
death--abused to the extent of causing a rupture into the peritoneal
cavity--surgery must be resorted to as the only hope.

If a case survive an operation the patient is no wiser than he was
before, and knows nothing about avoiding another attack, for let it
be said loud enough to be heard by all, and with no fear of
successful contradiction, that if every child at birth should have
the appendix removed there would not be one case less of
appendicitis than there is with the appendix intact. Of course,
technically there could be no appendicitis without an appendix, but
the cecum would become inflamed just as readily.

No amount of forcing drugs given by the mouth can induce a movement
from above the constriction, but a great amount of pain can be
produced by attempting to force a passage. No one comprehending the
true state of affairs would be foolhardy enough to try to force the
bowels to move. The reader can readily imagine the great pain and
danger liable to follow cathartic drugs, for they stimulate severe
peristaltic contractions. The contractions drive the contents of the
small intestine against the inflamed cut-off, but there it must
stop. If the parts have become softened, which they do by the
inflammation, there is danger of perforation and an escape of the
contents of the bowels into the peritoneal cavity, after which
diffuse peritonitis and death follow. Surgery can hardly hope to
save such patients; in fact they usually die; this is why the
surgeon recommends an early operation.

If all cases are to be so abused and if there were no better way to
treat them I also should say, operate at once as soon as the disease
is discovered; but I know from years of experience that there is a
better way to care for these patients.


Allow me to repeat: As soon as a case is diagnosed the proper
treatment is to stop all medicine and food, for they excite
movement, and this should be avoided. Give nothing but water. Keep
ice over the inflamed spot. Keep the patient quiet, end the feet
warm. There is absolutely nothing to be done until the bowels move,
which will take place in from fourteen to twenty-eight days. The
patient will not starve to death, nor will there be any danger that
the abscess will open anywhere except into the bowels. After the
bowels move, one glass of hot milk is to be given three times a day,
so there will be no danger of solid food finding its way into the
cavity of the abscess.

To be safe I insist on a fluid diet for a week after the bowels
move, and a light diet for two or three weeks more. Cases taken
through in this way, and then instructed in never allowing the
bowels to become loaded again, will not only make a good recovery,
but there is no tendency for the disease to return if the patient is
prudent. I say that there need not be a death from this disease if
these suggestions are properly carried out. The cases that die every
year are killed by food and medicine.

Surgery has gained its reputation in these cases because of the
stupidity of the average physician and patient. Cases taken through
in this way are comparatively comfortable; they may pretend to
suffer from hunger, but it is principally imagination. If my plan
were generally adopted the dread of this disease would disappear;
surgeons would get left on some fat fees, and the undertaker would
look glum after the fall crop.

There are a few laymen so willful and incorrigible that they can't
be depended upon to follow instructions. They will break rules, be
imprudent in eating, and in many ways disregard their own interests.
Such cases should be sent to the surgeons as early as possible,
before they have time to complicate their disease and make a
complete recovery impossible; however, people with such temperaments
usually find an early grave and they might as well go by the
surgical route as any other.

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