Article 10


FIRST-AID FOR APPEDICITIS?

Lim Ju Boo


Occasionally when friends come a visiting when I am busy typing out a story for the newsletter, they come with weird products, bizarre ideas, and ask me cranky questions which I do not know how to answer. This happens to me right now, with my eccentric, but well-loved friend of many years sitting right beside me seeing me type. He has a very kind heart, and is one whom I can joke and tease a lot harmlessly. I am very fond of him. His presence has not stopped me from writing, but instead makes me continue even more just to answer his chronic questions. Strange behaviour for both of us you might wonder? Actually, I have already planned to stop writing with the last one on ‘bends’, when this friend of mine came to find out exactly what am I typing the whole day. He said he was in fact trying desperately to contact me over the last 5 days without success. He had wanted to ask me to do some direct selling business with him. He said he is going to sponsor me for some big money with some of his weird products.

When I told him I have been busy writing articles about first-aid for our St John’s newsletter, he immediately got excited, and suddenly asked me out of the blue what the first-aid for appendicitis is? I was completely thunderstruck by his question. Never have I got a greater shock of my life …. I mean emotional shock, not one of those cardiogenic or hypovolemic shock (or almost) we have been learning in trauma cases all along. I have never even dreamt such question could even be asked even in my nightmares, let alone provide him the answer. Now he got me completely stuck.

At least he has now temporary forgotten his ‘direct selling business’, as he is more preoccupied that I give him the answer. At the moment I have no clue what is he trying to sell me directly. Whatever it is, I assure you I am not going to give my friend any commission, because he said he is now doing direct selling, which means there is no middle man involved. He broke into a broad smile when he saw me typing this. ‘Now, why are you smiling as if you have not seen daylight before my dear friend?’, I asked him. I told him there is no first aid for appendicitis, not that I know of, and even if there is, I do not know the answer, because I have not read it anywhere. But he insists that there is, and that I should give him the answer straight away. He said he won’t go away, until I am able to answer. He makes a good interrogator if he is in the Police Force. I asked him why of all things, he must ask me the first-aid for appendicitis as if it is some kind of urgency. He then told me it all happened like this.

It was only just yesterday his brother-in-law was discharged from the hospital after an appendix operation. A week ago he said his brother-in-law had a fever, vomited, was pale and had great pains ‘here and there’, somewhere all over his the ‘stomach’. His sister sent him to several doctors, but the pain and some vomiting persisted until he could no longer bear it any longer. So they were quite desperate, and finally they had to call an ambulance and bundled him to hospital where he was subsequently diagnosed and operated on. That’s the entire story he has to say, but the problem is, he insists to know the first aid for appendicitis before the ambulance arrives? It set me thinking a while, and finally I still told him there is no effective first-aid for this condition. I have not read it anywhere. I told him he has to get the patient straight to hospital for definitive treatment, since first-aid is only the administration of emergency assistance to an individual who have been injured or otherwise disabled before the arrival of a physician or transportation to a hospital. I told him appendicitis is a medical condition, relatively quite a ‘cold case’ but for which he still need to send the patient straight to a hospital. He will not die just because of the pain. But according to his whacky theory, he demanded that all the diseases and problems of this world, acute, chronic and terminal ones must have a first-aid first before the ambulance can be called. What Am I going to say to this eccentric friend of mine? I am at the moment getting very crazy myself listening to his argument in complete silence, so and I am now only forced typing out the answer in front of him as he talks to satisfy himself. And he is just grinning away. My answer to his question is still a big NO. ‘No to you crazy, I do not know any first-aid for appendicitis. You still have to send him straight to a hospital for investigations and treatment. No first-aid is required. The only thing is, don’t delay’ I warned.

‘Who wouldn’t get shaken when meeting weird friends like you, my spooky friend?’ I asked him. He broadened his smile into laughter. ‘I think you better join St John to understand what first-aid is all about, and our work better, okay?’ I told him. ‘How am I going to tackle such question like yours?’ I retorted. ‘The answer is I do not know, and I do not know a thousand times okay? I said to him. ‘In any case, appendicitis, unlike a cardiac arrest is not an immediate life-threatening situation that requires immediate first-aid assistance before you reach the doctor. Even if there is, you still cannot substitute definitive medical care with first aid or a home remedy. This is very important. Your only real risk in the acute stage of the condition if you delay medical treatment is a perforated appendix, with infected materials spilling into the peritoneal cavity’ I told him. But he still insisted that there is a first-aid to relieve the pain first. ‘Alright, you beat me. You beat me all the time, okay, as you always do okay, okay? Why don’t you argue with your sister? Your sister did a splendid job by sending her husband straight to the hospital without any first-aid, and he is now recovering uneventfully. Why do you pick me to hammer and bully all the time?’ I said to him. My friend laughed. He seems satisfied for a while, but not for long.

Now my friend was aware that I was formerly working for 25 years as a medical researcher and nutritionist at the Institute for Medical Research, Ministry of Health, Malaysian Government. He was also aware I am also interested in naturopathic (natural) medicine besides conventional allopathic (drug based) medicine.

My friend put it to me whether or not there was a naturopathic medical treatment for appendicitis? I still told him no again if he meant acute appendicitis. I told him a naturopathic doctor, just like his allopathic doctor counterpart still refers the patient to a hospital if it was an acute case of appendicitis. Definitive treatment by appendicectomy (surgical removal of the appendix) is usually the only answer. Naturopathic treatment is only offered for the sub-acute and chronic stages of the disease. All doctors whichever systems of medicine he practices have to stage the condition first before they offer any treatment.

It is just too risky to treat the acute stage of the disease through natural medicine only because of the risk of perforation and peritonitis. Briefly, from the naturopathic medical view point, I shall explain what appendicitis is all about.

Appendicitis is an inflammation of the vermiform appendix. This can occur in all ages, but generally in the younger age group between about 15 an 25. The condition may be staged as acute, subacute or chronic. ‘In your brother-in-law’s case, I believe it may have been an acute appendicitis from the symptomatology you described’, I told him. This is normally obstructive, with the lumen of the appendix narrowed by swelling of the lymphoid tissue in the region, or stricture from previous inflammation. There may be total obstruction by impaction of a faecolith that may result in gangrene, perforation and a local abscess, which may burst, and all the infected material and faecal matter released into the abdominal lining (peritoneum) causing infection and generalised inflammation in the area (peritonitis). Another outcome may be the formation of an oedematous inflammatory appendix mass.

The clinical feature is a history of sudden onset of vague central abdominal pain, followed by a shifting of pain to the right iliac fossa (the right concavity of the iliac bones of the pelvis) until it becomes localized to the McBurney’s point. During a naturopathic examination, the doctor presses over the McBurney’s point and look for what we called rebound tenderness. ‘Here is the McBurney’s point, this part my dear friend, one third the distance along the line from the anterior superior iliac spine to the umbilicus’ I said as I showed it to my friend. Generally in the acute phase, there is nausea and malaise as in your brother-in-law’s case. Sometimes, there may be vomiting. In the initial stages there may be little elevation of body temperature, and the presence of chills and high fever make the diagnosis of appendicitis unlikely. There is tenderness and guarding in the right iliac fossa, which may progress to rigidity as peritonitis sets in.

However these classical features occur in just half of the patients because of variations in the anatomical sites of the inflamed appendix. Thus it is important to make a differential diagnosis to differentiate it from other abdominal diseases such as acute mesenteric adenitis, perinephric abcess, Meckel’s diversion, irritable bowel syndrome, Crohn disease, pyelonephritis (inflamation of the kidney), and disorder of the fallopian tube and ovary, if you are a female. That makes diagnosis very difficult because you cannot depend on symptomatology only, because there are other conditions that mimic appendicitis. The doctor, whether he is an allopathic or a naturopathic doctor may do a rectal examination, or even an exploratory laparotomy to confirm or exclude a diagnosis of appendicitis, while a naturopathic physician will examine for certain tell-tale signs in the iris of the eyes, and palpate for rebound tenderness over the McBurney’s point.

‘Here, let me examine your eyes, and let me also palpate over the McBurney’s point over here’. I said to him. You are sitting, but if you are in the supine position (lying flat facing upwards) and I press down here at the McBurney’s point, and suddenly release my hands, you might feel a sudden increase in pain over the area (rebound tenderness). ‘Did you feel any sharp pain here when I pressed and released my hand?’ I asked. ‘Oh, you were just giggling away instead of saying ‘Ouch’, I remarked as I pressed and released the lower right part of his abdomen once again. Oh well, you have no appendicitis I told him. If a blood test is taken, the leukocyte (white cell) count may be increased, especially the polymorphonuclear cells. This condition we call polymorphonuclear leucoytosis.

If a diagnosis for acute appendicitis is confirmed, an appendicectomy has been done to avoid the risk of perforation and peritonitis. This procedure is mandatory. There is no substitute for this. But from the naturopathic medical stand point of view, the application of a hot bottle/bag, or a cold compress over the area, or the application of Transcutaneous Electrical Nerve Stimulation (TENS), is useful; whichever is most suitable or comfortable to the patient for relief pain. This is the only first aid I know from the naturopathic medical point of view until more definitive treatment is available.

Again, there is also a big definite big ‘NO’ to laxative, food or even water, or anything to be given by mouth. In naturopathy, we encourage fasting, because we don’t want to encourage peristaltic (intestinal) hurry, which will cause waves of intestinal contraction that can aggravate the pain. Intestinal hurry itself may encourage perforation. If we are taking about first-aid in naturopathic medicine, we encourage FASTING AND COMPLETE BOWEL REST because we want to IMMOBILIZE COLONIC MOVEMENT as much as possible until a surgical approach becomes available. Remember this is like putting a splint over an injured limb to restrict movement. I am sure you understand this in first-aid.

That is why from the naturopathic stand point of view, the accompanying vomiting, sometimes associated with the condition is a natural physiologically protective mechanism to prevent more food from reaching the colon. Finally, no pain killers to mask the condition please. Keeps the patient warm and comfortable while waiting for an ambulance? But the treatment is quite different for sub-acute and chronic stages of the disease, where an operation may be unnecessary. In such cases there are lots of naturopathic options, but I shall not discuss them here because it is very lengthy and unnecessary.

McBurney’s point:

‘That’s all I need to tell about first-aid method for appendicitis, my dear nosy friend. But please don’t ask me now what is the first-aid for cancer before the ambulance arrives. I will be sunk straight away’. I told my friend ‘Why are you continuously wearing that mysterious Mona Lisa smile as I type out these sentences to answer to your cheeky, eccentric question ? It’s more like the grin of an alley cat to me.’ I remarked.

My stars gave me no luck:

‘Now let me see what’s inside this dirty old treasure bag of yours which you said contains some products to make me rich right away? I hope it’s an old Aladdin Magic Lamp which I can rub straight away. I have always been looking for a genie, or something like that to get rid of my bad luck. You know, I was born without any stars in heaven. It was completely blank, and a washed out for me - all blank with rain clouds everywhere, so I was told by my mother. I was born near midnight in driving rain when our faithful and dedicated family midwife rushed to our pre-war colonial shop house to deliver me on March 20, 1939.

The whole sky was completely in thunderstorm. I hope your ‘direct product’ can dry out all that, and bring me some ‘direct luck’ this time. That why I have never bought a horoscope book to read to find out what’s inside, nor have I consulted a fortune teller. Whatever for I buy a horoscope. It is all full of rainstorms inside, page after page’. I told my friend, as he busted out in loud laughter. ‘I bought a copy now only because I am curious about my Commander-in-Chief horoscope, as well as those of my Regional Commander, Dr. Lee Hoo Teong, and Mr Abu Hassan, the Chief Surgeon’. I assured him.

Wow! There you are, my friend. I won’t tell my readers what you brought for me I remarked.