SOME REMARKS UPON A YEAR’S WORK IN APPENDICITIS. BY J. H. CARSTENS, M.D., DETROIT, Ex-President of the American Association of Obstetricians and Gynaecologists ; Professor of Obstetrics and Clinical Gynaecology in the Detroit College of Medicine; Chief of Staff and Gynae- cologist to Harper Hospital, etc. REPRINTED FROM THK "Mcto Yotlt jaeatcal for May 16, 1896. Reprinted from the New York Medical Journal for May 16, 1896. SOME REMARKS UPON A YEAR’S WORK IN APPENDICITIS. By J. H. CARSTENS, M. D., DETROIT, EX-PRESIDENT OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNAECOLOGISTS; PROFESSOR OF OBSTETRICS AND CLINICAL GYNAECOLOGY IN THE DETROIT COLLEGE OF MEDICINE ; CHIEF OF STAFF AND GYNAECOLOGIST TO HARPER HOSPITAL, ETC. When we consider that a few years ago the word “ ap- pendicitis” had not even been coined, and if we then think how physicians can report a great number of cases and many operations, we get a general idea of the wonderful progress of medicine. My fossil friends in the profession say appendicitis is a great fad. They ask, “ How is it you see so many cases? We so seldom see them.” Still, it is very easy. If you will think for a moment that my cases come to me from a radius of hundreds of miles, and nearly all sent to me by physicians whose combined practice represents a million population, and if you average it, there are not so many cases of appendicitis. At the Harper Hospital last year we had thirty-one cases ; every hospital in the city has had a number. A good many patients have recovered with- out going to the hospital, some even not recognized. From Copyright, 1896, by D. Appleton and Company. 2 A YEAR’S WORK IN APPENDICITIS. the best information I can get, it seems to me there oc- curred in this city alone about one hundred cases of appen- dicitis—certainly not more than one hundred and fifty— giving about one case to every two thousand of the popu- lation. The physician who has two hundred families (that would be about seven hundred people to treat) has a pretty good practice; hence, the physician with a fair practice would see a case of appendicitis about once in three years (this general average may be too high or too low, hut 1 think I am pretty near to it), so that my friend the general practitioner is perfectly right when he says appendicitis is not a very common disease; while the abdominal surgeon is also correct when he talks and reads about it a great deal, as he sees a great many cases comparatively. This disease was formerly seldom recognized; it was said that a patient died of peritonitis ; but by his attention having been called to it repeatedly the general practitioner is now aroused, is constantly on the lookout for it, and finds appendicitis where formerly he would not have suspected it. Another point about this disease is that some general practitioners maintain that it is a mild one and easily sub- sides with simple treatment—such as with opium, ice bags, and hot poultices—and I have had physicians tell me that they had had eight or ten patients all recover, or perhaps only one die in fifteen to twenty cases, and that I, as an operator, could show no such record. I do not get the easy cases. I get them when medical treatment has failed. Even when they are in articulo mortis, I find I am expected to do magic. What we maintain is that all patients with appen- dicitis should be seen by the surgeon jointly with the family physician, and as a rule operated upon; although a very small percentage will have only one attack, the vast majority (from my experience I should say from eighty five to ninety per cent.) will have recurring attacks, and during the sec- A YEAR’S WORK IN APPENDICITIS. 3 ond, third, or tenth attack rupture will take place and the patient will die, not to say anything about the pain and suffering he has to undergo in the meantime. All cases of peritonitis not due to puerperal or pelvic diseases in women are caused by appendicitis, except four per cent., which are due to perforation of the bowrels caused by ulceration and malignant growths, etc. During the year 1895 I operated in seventeen cases of appendicitis. In these seventeen cases there had been altogether forty-six different attacks. Some of these attacks were mild and some were severe. Some of the patients were repeatedly confined to bed for from six to twelve weeks. They were suffering from septicaemia and hence were invalids. My cases were as follows : Case I.—Mr. M. R., aged thirty-three years (kindly direct- ed to me by Dr. Galbraith, of Pontiac). The patient had had four attacks, some of them being quite severe. I operated on him January 2, 1895, at Harper Hospital. He was free from acute symptoms. I dissected the peritoneal covering, sewed it over the stump, and closed the abdominal incision in layers, using kangaroo-tendon sutures throughout. He made an un- interrupted recovery. Case II.—Miss M., of Ontario, aged twenty-two years (kindly sent to me by Dr. Mulhern). She had had three at- tacks. She seemed in very good health, but, when the abdo- men was opened at Harper Hospital, I found that she had tuberculous peritonitis—something I had not expected. I removed the appendix and washed out the abdomen with bichloride solution. I sewed the incision with en masse suture of silkworm gut. What connection there was between the tuberculous condition and appendicitis I do not know. The patient has entirely recovered. Case III.—Mrs. C., aged twenty-five years (kindly sent to me by Dr. Aaron). Six attacks; also had chronic tubal disease. Operation at Grace Hospital. Appendix removed with the ovaries and tubes, one tube being a beautiful specimen of 4 A YEAR’S WORK IN APPENDICITIS. hydrosalpinx four inches in diameter. Recovery “ smooth,” as the Germans say. Case IV.—Miss A., of Lansing, aged twenty-five years (kindly directed to me by Dr. Gannung). She had had six attacks. During some of these she was confined to bed for three to four months. I operated on her, May 18th, at Har- per Hospital during the quiescent stage. Used kangaroo-ten- don suture. She made an ideal recovery. Case V.—Mr. W., of this city, aged eighteen years. Called by Dr. Schulte to see him on Sunday afternoon. This patient had been sick for forty-eight hours and had a temperature of 108° F. Careful investigation showed that he had had a slight attack some months before. I had him immediately removed to Harper Hospital, and operated on him the same day, May 26th. Perforation had taken place and the appendix was re- moved. Gauze drain used, and the wound closed with en masse suture of silkworm gut. Case VI.—Mrs. L„ aged twenty-one years (directed to me by Dr. Moran, of this city). She had had four attacks Agreed to come to Harper Hospital on Wednesday to be oper- ated upon. On Tuesday afternoon she was taken with an- other attack. I immediately had her removed in the ambu- lance to Harper Hospital, where I operated on her, May 28th. The appendix was club-shaped and apparently upon the point of rupturing. It was removed and the wound closed with buried kangaroo-tendon suture. She made an ideal re- covery. Case VII.—Miss H., aged ten years. Kindly called by Di\ Hastie to see this little girl. She was taken with appendi- citis, properlyr diagnosticated by the doctor, but it seemed to be a very mild attack and the symptoms had all subsided, so that she was thought to be well. But on the eighth day the fever rose to 101°; ninth day, 102°; and the tenth day, 103°. The swelling of the right inguinal region increased in the same proportion. I had her transferred at once in an ambulance to Harper Hospital, where I performed the operation imme- diately. The abscess was opened and drained, but the ap- pendix was not removed, as I thought it had sloughed off. A YEAR’S WORK IN APPENDICITIS. 5 The patient made a good recovery, and has been perfectly well ever since. Case VIII.—Mr. J. B., of Grosse Point, aged thirty-six years. Kindly directed to me by Dr. J. Bennett. I saw him during the acute stage of the second attack, hut as he was on the mend did not operate. He recovered sufficiently to be out, but always complained of pain in the region of the ap- pendix. I saw him again and urged an operation, but as he did not seem very sick he postponed it from week to week. Finally he became frightened and went to St. Mary’s Hospi- tal, where I operated on him, July 1st. I found he had re- lapsing appendicitis. Removed the appendix and used gauze drain, closing the wound with silkworm-gut sutures. He made a good recovery. Case IX.—Mrs. W., aged thirty-five years. Seen by re- quest with Dr. Schell. This patient I had operated on three months previously for salpingo-oophoritis. Immediately after the operation she had symptoms of appendicitis, hut these soon subsided and she seemed perfectly w ell. Six weeks later, how- ever, she again began ailing, and was confined to her bed, be- coming weaker and weaker. She had quite a fever; tem- perature, 108° ; pulse, 130. The pain was excruciating in the region of the appendix. I had her removed in an ambulance to Harper Hospital, and operated on her on July 2d. I found the appendix much inflamed and adherent. I removed it, but also found a small cheesy abscess of about the size of a bean buried in the right broad ligament. It has always been a question to my mind if that was not the cause of the fever. Unfortunately, I had no bacteriological examination made. Subcutaneous saline infusion was performed during the opera- tion, as she was very weak. She thoroughly recovered with- out a bad symptom. Case X.—Mr. M. A., aged forty years. Kindly sent to me by Dr. Shorr. He had had appendicitis for three days, and this was apparently his first attack. I had him removed to St. Mary’s Hospital, and operated on him on August 3d. The appendix was gangrenous. Used gauze drain and silkworm- gut sutures. But after the operation he was taken with symp- 6 A YEAR’S WORK IN APPENDICITIS. toms of delirium tremens, and died within forty-eight hours, suddenly, of heart failure. Case XI.—Minnie S., aged two years and a half, of Fow- lerville. Kindly called out there by Dr. Austin. This little girl had had four or five attacks, properly diagnosticated by the doctor as appendicitis. I found the appendix ruptured and gangrenous. Operated September 16th, using gauze drain and silkworm-gut sutures. She made an excellent recovery. Case XII.—Mr. C., aged thirty-five years, of Tecumseb. Dr. North called me there to operate for appendicitis. I found the diagnosis correct, and removed the ruptured ap- pendix, September 12th. Used gauze drain and silkworm-gut sutures. This patient also made an excellent recovery. Case XIII.—Mr. O., aged fifty years. Called to see this patient by Dr. Bonning. This man weighed two hundred and fifty pounds and was formerly a heavy drinker. The first attack of the disease and of forty-eight hours’ dura- tion. Appendix was gangrenous; considerable general peri- tonitis. Operated on September 14th, using gauze drain and silkworm-gut sutures. He died of sepsis three days afterward. Case XIV.—Mrs. M., aged thirty-four years, of Fowlerville. Kindly asked to come out there by Dr. Austin and operate on this patient, who had had four or five mild attacks of ap- pendicitis. Found the appendix unruptured. I operated on September 30th, using kangaroo-tendon sutures. She made a good recovery. Case XV.—Mr. C., aged thirty-four years. Dr. Goodwin asked me to see this patient. He had been suffering for five days with symptoms of obstruction of the bowels. I diag- nosticated appendicitis and had him removed to Harper Hos- pital. I operated on him on October 30th. The appendix was twisted around the caecum in such a way that it caused ob- struction of the bowels. Vomited constantly for five days. Although he had a passage from the bowels after the opera- tion, he remained weak and unable to take any nourishment. He died on the sixth day, of debility. His temperature was only 99°. A YEAR’S WORK IN APPENDICITIS. 7 Case XVI.—Mrs. L., aged thirty-one years. Kindly sent to me by Dr. Willson, of Port Huron. She had had a number of slight attacks of appendicitis, and a long time before severe pelvic inflammation. I agreed to remove at the same time the tubes and ovaries, if necessary and possible. The appendix Was very much inflamed and adherent, and the ovaries and tubes were buried in a mass of adhesions. I removed both, using kangaroo-tendon suture throughout. Case XVII.—Mrs. F., aged thirty-eight years, This pa- tient had had two attacks of appendicitis. After the last attack she agreed to have an operation. While I was out of the city, on November 19th, she was taken with another at- tack, and, becoming very much frightened, she immediately went to Harper Hospital, where I found her, late at night after my return. I had her prepared, and operated on No- vember 20th. Used kangaroo-tendon suture. She recovered. Case No. Number of attacks. STAGE. Acute. Quiescent. 1 Mr. R 4 0 1 2 Miss M. 2 0 l 3 Mrs. C 3 0 1 4 Miss A 6 0 1 5 Mr. W 2 1 0 6 Mrs. L 5 0 1 1 Miss H 1 1 0 8 Mr. B 3 1 0 9 Mrs. W 1 0 1 10 Mr. P 1 1 0 11 Mary S 4 1 0 12 Mr. C 2 1 0 13 Mr. 0 1 1 0 14 Mrs. M 4 0 1 15 Mrs. L 3 1 0 16 Mr. C 1 1 0 11 Mrs. P 3 0 1 Totals 46 9 8 These seventeen cases represent forty-six different at- tacks, leaving twenty-nine attacks which were treated on 8 A YEAR’S WORK IN APPENDICITIS. general principles, without a death, so that the general practitioner can say he had twenty-nine cases without a death, while I had seventeen cases with three deaths. But if I should add to this list the cases I have seen during the year in consultation, in which an operation was not per formed and the patients died, T could give the general prac- titioner, as the hoys say, “double discount.” If in the light of our present knowledge we take one hundred consecutive cases, and have the patients treated by constitutional and local medications, how many do you think would die ? Then take one hundred consecutive cases of operation within twenty-four hours, or as soon as the diagnosis is made, in how many of this class of cases would the patients die ? All men of experience will to-day admit that in the first class of cases four times as maDy patients would die; and then I will admit that unquestionably, of the surgical cases, ten or fifteen per cent, of patients will be operated upon who would have recovered permanently and without recurrence if no operation had been performed. If surgical treatment shows the best results, that is the correct plan. To sum up, I should say : 1. Excluding the pelvic peritonitis of women and traumatic cases, peritonitis is always appendicitis. 2. Appendicitis is a surgical dis- ease. 3. An immediate operation will give the best results. 620 Woodward Avenue. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a live weekly medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. 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