TABLE NO. 2.-AGE. Acute Mortality Chronic Cases in Acute Cases Totals Cases Number of Cases Per cent. of whole Number of Deaths Per cent. in each Number of Cases Per cent. in each Number of Cases Per cent. in each TABLE No. 1.-VARIETIES, NUMBER OF CASES AND MORTALITY IN EACH. Analysis of the Mortality.-(See Table No. 1.) The total number of patients operated upon was 1,411, of whom 72 died, or a mortality of 5 per cent. 212 of these, however, were cases in which the appendix was removed in association. with other procedures, which leaves 1,199 operations for some variety of appendicitis. These latter alone will now be considered. In any given statistics the mortality rises and falls with the relative number of acute (and complicated) and quiescent (chronic and relapsing) cases operated upon, and to obtain a fair view of the actual operative mortality it is necessary to divide the operations into two distinct classes: 1. Those performed during quiescent periods of the disease, i. e., for chronic and relapsing (interval) conditions. 2. Those performed in the presence of acute lesions. 1. Chronic and relapsing conditions. (See Table No. 1). In this category there were 512 operations performed with 3 deaths, or a mortality of 0.5 per cent. These 3 deaths were as follows: One patient died on the 21st day after operation of lobar pneumonia and pulmonary thrombosis. The second patient died on the 4th day of acute nephritis (suppression). The third patient died on the 4th day of general septic peritonitis, due to the slipping of the ligature off the base of the appendix. In this case two plain catgut ligatures had been used without any subsequent burying of the stump. While a number of authorities advocate this method of treating the stump, the additional burying of the base of the appendix seems wiser and safer. Comment on these 3 deaths is unnecessary except to say that two of them were unavoidable, while the third should not have occurred. A number of cases where the ligatures have slipped from the stump are reported, however, e. g., in the report of 2,000 appendix operations performed at Mt. Sinai Hospital, New York (Moschcowitz, Archiv. für Klin. Chir., Bd. 82, Heft 3), this accident occurred in 2 cases. 2. Operations performed in the presence of acute conditions: ((See Table No. 1.) Under this category there were 687 operations, with 68 deaths, or a mortality of 9.8 per cent. Brewer in his Surgery (1909) makes this statement as to the mortality in the acute cases: "In early acute cases when the inflammation is limited to the appendix, the mortality should not exceed 2 or 3 per cent., in abscess cases not greater than 5 per cent., but in late neglected cases where there is a diffuse peritonitis, the mortality will be from 50 to 80 per cent., the former figure representing the mortality to be expected in children, the latter in adults." In the present statistics there was a mortality of 1.6 per cent. (364 patients, 6 deaths), in the early acute cases limited more or less to the appendix. In the abscess cases with removal of suppurative or gangrenous appendices, the mortality was 5 per cent. (180 patients, 10 deaths). In the abscess cases without removal of the appendices, the mortality was 23 per cent. (60 patients, 14 deaths). There was a mortality of 42 per cent. in the late cases with general peritonitis (83 patients, 35 deaths), i. e., in children of 10 years or under, the mortality was 50 per cent. (14 cases, 7 deaths); in patients with general peritonitis over 10 and under 20 years of age, the mortality was 38.4 per cent. (26 patients, 10 deaths); while in adults over 20 years of age with general peritonitis, the mortality was 48.4 per cent. (43 patients, 21 deaths). For a satisfactory estimation of the results of operations during the acute stages, the classification adopted by Sprengel is the most convenient. Thus, "Early Operations," those undertaken during the first 48 hours; "Intermediate Operations," those performed from the 3d to the 6th day inclusive, and "Late Operations," those performed from the 6th day onwards. The present status among surgeons of the question of operating in acute appendicitis may be fairly stated briefly as follows: I quote freely from Murphy (Keen's Surgery, Vol. IV, page 773): "From the clinical course and pathological changes, it is evident that the most favorable time for operation it within the first 32 hours of the attack (early operations) or, from a pathological basis, before perforation of the appendix or infection of the periappendicular tissues has taken place. The diagnosis can and should be made with accuracy in the great majority of cases before the end of the first 24 hours. From the symptoms and clinical course of the disease in the first 48 hours, it is impossible to predict with any degree of cer tainty what the subsequent course of the disease will be—that is, whether the tendency will be to subsidence and cure by the natural processes or to a virulent course, if not fatal termination. The danger of operation in this stage is but a trifle above that of the operation undertaken in the interval, while the patient is spared the dangers of serious complications." In short, patients with acute appendicitis in the early stage should be operated upon immediately, and this statement voices the views of most surgeons generally in America, including Dr. Ochsner and his followers. The intermediate stage, from the 3d to the 6th day inclusive: The question of whether to operate or not during this period is the crux of the whole appendix situation and, unfortunately, at the present time, authorities differ as to the better plan of procedure. I quote again from Murphy: "Should we operate in the second (intermediate) stage, during the increasing or spreading inflammatory process, which may mean anywhere from the second to the fifth day? In this stage we may have the circumscribed abscess around the appendix, an active inflammatory process of the neighboring tissues or organs, or the early pathologic changes of a circumscribed or general peritonitis. We often find the temperature and pulse high, meteorismus, intestinal paralysis, and acutely infected tissues, with manifestations of severe intoxication at this stage. Shall we then operate?" The answer to this question divides the surgical world into two camps: the one advocates the Ochsner treatment of diminishing peristalsis and delaying operation in the hope that the diffuse or general peritonitis will subside into a local process and form a circumscribed abscess which can be opened later when the severe abdominal symptoms and general toxæmia have subsided. Some of their statistics are alluring (e. g., Guerry, Jour. Amer. Med. Assoc., January 1, 1910), but before being convincing, it will be necessary to know how many of the patients, treated in this way, die without localizing the process into an abscess, hence go unoperated. I have seen no such statistics. Patients who have strength enough to survive the battle are operated upon and the unfit are eliminated. This method seems ideal for the statistics of the operator and perhaps better calculated to minister to the surgeon's reputation than to the safety of the patient. How is anyone to tell in advance whether a given spreading or diffuse peritonitis will not go on to a general and fatal peritonitis? Unquestionably it will not do so in the majority of cases, but it is the minority that we must seek to save. The Ochsner method of treatment has been widely misunderstood and wrongly applied. Many have falsely interpreted it to mean that operation in all acute cases, even in the early stage, should be delayed, and great harm has been March, 1910 done because of the letting slip by of the most favorable time for successful operation, namely, at the outset. Perhaps it would be well to outline the Ochsner method of treatment in order that there may be no misunderstanding as to exactly what is meant. We may divide it into two parts -the first finds no dissenters among surgeons and relates to efforts to be used to diminish peristalsis, hoping thereby to limit the spread of the inflammation. It consists in the use of gastric lavage, the giving absolutely of no nourishment of any kind and no cathartics by mouth, the giving of no large enemata, the continuous administration of normal salt solution by rectum by the drop method, and the giving of nourishment exclusively by the rectum, and perhaps a modified Fowler position. The second and more criticized portion of the Ochsner treatment consists in the delaying operation in the severe (intermediate or late) cases (and these only, be it noted), in the hope that by the employment of the means outlined above peristalsis will be so diminished as to limit the spread of the diffuse or general peritoneal inflammation and that a local abscess will form which can later be opened. Further discussion of this topic will be carried on when considering mortality figures. The second camp is made up of those who answer the question of whether to operate in the intermediate, or dangerous, stage by a Yes. Morris (Jour. Amer. Med. Assoc., January 1, 1910, Page 11), puts it as follows: "The Ochsner treatment is one of the most important things that was ever brought forward, but instead of carrying it out exactly as Dr. Ochsner does, I believe in doing an operation consuming 3 or 4 minutes. Get in, snap forceps on the appendix and put in a little drain. You are not doing much to that patient. You are not lessening his chances very much." All the operators in the Presbyterian Hospital belong to this second camp and the statistics in this paper are made up of cases, with a few exceptions only, treated on such lines, viz., no delay in operating in all stages of the disease. A medical colleague (Fussell, New York Medical Jour., January 22, 1910, p. 175), puts it well, as follows: "I thoroughly believe that at least three-fourths of the cases of appendicitis would recover if not operated upon, but I know there are no symptoms that will tell when any case is approaching the danger line until it is extremely dangerous either to interfere or to wait. I have said that the time to operate is when a diagnosis is made. I believe this holds good whether a diagnosis is made early or late. I am well aware that some of the best surgeons are opposed to this action. They teach that after a certain stage is reached it is safer to wait for resolution or an abscess and then operate. Truly, if we were sure that the case would not perforate or sure that the abscess would not rupture into the abdominal cavity, that is good advice. But no man can be sure of this. We can be sure of a very small mortality if a good surgeon operates at any time. It seems just as rational to operate if there is pus in the abdomen, whether it be due to appendicitis or to a perforated ulcer." Factors Inflencing the Death-Rate.-We have already noted the effect which the age and the sex have upon the prognosis. It would be instructive to examine the acute cases to see how the presence or absence of previous attacks and the duration of the disease at the time of operation influence the prognosis. Previous Attacks in the Acute Cases.-By reference to Table No. 3, we find that of the 647 acute cases in which the presence or absence of previous attacks are given, 34 per cent., or a little over a third of the patients, had had one or more previous attacks, while 65 per cent., or a little less than two-thirds, had had no such previous attack. In a general way we may infer by analyzing this table that the milder the pathological lesion, the more likely is the patient to have had one or more previous attacks, and the severer the lesion the less likely. Thus in the acute catarrhal cases, 55 per cent. had had previous attacks; in the next severer type, the suppurative, 39 per cent, only had had previous attacks, while in the acute suppurative and gangrenous cases with abscesses, 30 per cent. gave a history of previous attacks. 26 per cent. of the patients with the severest lesions, those with general peritonitis, or a little over a quarter of the patients so affected, had had previous attacks. The most striking fact, however, is elicited from this table from the fatal cases. But 14 per cent. of the fatal cases, or about one-seventh, had had previous attacks. We may infer from this, I think, that antecedent attacks tend to surround the appendix with protective adhesions, so that in a subsequent attack general peritonitis is less likely to occur. But statistics show that of the patients with acute inflammations who had had previous attacks, the recurrences took place in 38 per cent. (somewhat over a third) within six months, 66 per cent., or two-thirds, within the first year, and 82 per cent., or somewhat over four-fifths, within two years of the first attack. TABLE NO. 3.-PREVIOUS ATTACKS. A trifle over half the patients (53 per cent.) who had had previous trouble (see Table No 4), had had but one previous attack, 21 per cent., or somewhat over one-fifth, had had two attacks, while 25 per cent., or one-quarter, had had more than two previous attacks. TABLE NO. 4.-NUMBER OF PREVIOUS ATTACKS, Acute Catarrhal. Total, 647 cases Fatal cases, 58 None 40, or 44.4°/ None 55, or 73.3°。 Whatever may be the difference of opinion as to the best treatment of the acute cases after the second day of the disease, surgeons are generally of the opinion that the greatest factor in reducing the mortality is the earliest possible removal of the appendix after the onset of the disease. Thus, 20 of our cases were operated upon within 16 hours of the beginning of symptoms, only one of whom died (64 years old) on the 9th day after the removal (10 hours after the onset) of a suppurating appendix, from a complication (acute pericarditis in association with chronic valvular disease) which could neither have been foreseen nor avoided. In this fatal case the abdominal conditions at the time of death were perfectly JOURNAL OF MEDICINE satisfactory. We may venture to assert, then, that operations for acute appendicitis performed within 16 hours of the onset will commonly result in no mortality, except that due to very exceptional circumstances. There were 115 patients operated upon between the 16th and 24th hours after the onset with a mortality of 4, or 3.4 per cent. 3 of these 4 patients had gangrenous appendices with spreading or diffuse peritonitis and died on the 3d, 6th and 22d days after operation as the direct result of peritonitis, i. e., sepsis. Smears and cultures of the exudate showed the infections in one to be caused by streptococci with colon bacilli, in the second by streptococci alone, and in the third by pyocyaneus with colon bacilli. The fourth patient had a gangrenous appendix and died on the 9th day of sudden pulmonary embolism, that apparently unavoidable complication which may be met with in almost any operation of whatever nature. Such cases illustrate only too strikingly how treacherous this disease may be even within a comparatively few hours of the onset and how necessary it is that, unless definite contraindications exist, operation should be undertaken at the very outset without waiting for the development of symptoms indicating whether the attack is going to be a mild or severe one. Murphy says (Keen's Surgery): "To me there appears to be no excuse, no explanation, no logical process for, no justifying hope in, delay in this disease." These fatal cases make one face the discouraging fact also that, operate however so early we may, there is likely to be a certain unavoidable mortality. With the passage of time after the first day the mortality mounts. Thus, on the second day, there were 145 patients operated upon with 9 deaths, or 6 per cent. of those operated upon during that time. Peritoneal sepsis was directly responsible for death in 6 of these cases, 2 others died after operations for intestinal obstruction, while the 9th died of penumonia. Of 103 patients operated upon on the 3d day, 8 died, or a mortality percentage of 7.7. The 4th day gives a death-rate of 18 per cent. (72 operations, 13 deaths). The operations on the 5th and 6th days are about equally fatal, each 14 per cent. If we combine the operations performed from the 3d to the 6th day inclusive the mortality is 12.7 per cent. This is the so-called dangerous period in which Ochsner and his followers do not operate on the severe cases but wait, expecting to open a local abscess later. What are the results if we do Before answeroperate later than the 6th day? ing this inquiry with figures, let us see what the adherents of the Ochsner treatment believe to be the best days on which to operate. In a remarkable series of appendix operations published by Guerry (Jour. Amer. Med Assoc., January 1, 1910, p. 4) and treated by the Ochsner method, he says that the patients coming into his hands on the 3d and 4th days were tided through this period of great danger and "several days" later were safely operated on for localized appendicitis. Again, Haggard (same journal, p. 10) suggests waiting until the 10th to the 14th day. Stanton (same journal, p. 10) says, "If things are let alone for a few days it will be found that all these patients at the 8th or 9th days have localized abscesses, an easily treatable -surgically drainable-lesion. These abscesses should not be allowed to go on beyond this period, for it is after the 12th day that we find the pus beginning to seek exits of its own, pyemia, metastatic abscesses, etc. If we take Guerry and Stanton's time to operate as any day from the 7th to the 10th, by analyzing our statistics (see Table No. 5), we find that we have not gotten as good results as though we operated from the 3d to the 6th day inclusive. For, from the 7th to the 10th day inclusive, the mortality was 20 per cent. of those operated upon during that period (79 operations, 16 deaths), as against a mortality of 12 per cent. of those operated upon from the 3d to the 6th day inclusive. If we take Haggard's time for operation as from the 10th to the 14th day inclusive, we find that the mortality is 15.3 per cent. (52 cases, 8 deaths), which is a somewhat better showing than operations performed from the 7th to the 10th day inclusive, but not so good as the results obtained when the operations were performed from the 3d to the 6th day. I submit that there may be a different type of appendicitis in New York City from that found in South Carolina, Tennessee or Illinois. Our patients are drawn from the poor sections of the east side of New York City and are ill calculated to withstand and overcome prolonged sepsis such as must occur if the Ochsner treatment be carried out. It may be that acute appendicitis requires different treatment in various sections of the country. Let me instance 4 cases treated according to the Ochsner method, all with fatal results. CASE 2087. Male, 32, sick 14 days, localized abscess, size of adult head. Incision, appendix not removed. Seven days after first operation, subdiaphragmatic abscess opened in 10th space, posterior axillary line, under cocaine anæsthesia, evacuating a pint and a half of pus. Death three days later from exhaustion. CASE 2462. Male, 51, sick five days, condition poor, very tender and rigid over whole right half of abdomen. Ochsner treatment until the 10th day, then operation. At least a quart of thick, fecaloid pus escaped. Cavity extended from liver to pelvis. Gangrenous appendix lay loose in cavity. Ligature to stump. Drainage. Time of operation, 15 minutes. Died on the second day following of exhaustion. CASE 4110. Male, 43, sick 2 days. On admission great distension over whole abdomen, vomiting every few moments. Ochsner treatment until 7th day. Slight general and local improvement but not sufficient to warrant further delay. Incision in right side, evacuating in a spurt large quantities of pus under great tension. No search for appendix. Drainage. Died on the 2d day from exhaustion. Sick 3 CASE 895. Female, 17, pregnant 6 months. days. Ochsner treatment until 8th day, then opera tion. Gangrenous appendix removed and an extensive abscess evacuated of which the large uterus formed one wall. Aborted 9 hours after operation. Death on the 3d day after operation of exhaustion. In patients such as we see, a few experiences such as the above have discouraged us from wide application of the Ochsner method. In 3 fatal cases with severe symptoms (all had gangrenous appendices with general peritonitis, and of 2, 5 and 7 days' duration respectively), the blood contained, as shown by cultures, in one case streptococci, in the second colon bacilli, and in the third staphylococcus aureus. Few such cases will be saved by any form of treatment, but is it not much more rational to at once remove the primary focus and to divert it externally by drainage, so as to diminish as much as possible the absorption of organisms, than to adopt the expectant method of delayed operation trusting the patient to take care of such an amount of infection unaided. Under the Ochsner treatment I believe none of these cases of septicemia would have reached the time for operation, but our statistics in that event would have been improved by just so many fewer fatalities. While on the subject of the mortality, it may be pertinent to say that the incision of abscesses alone without the removal of the appendices has not proved very satisfactory. (See Table No. 1.) Deaver (Annals of Surgery, December, 1909) voices the same sentiment. Haggard, in the article quoted above, says this: "There are a great many delayed cases in my section of the country and we operate on these simply by incision and drainage. We do not bother about the appendix and all the patients recover." We do not get such results in New York, for of 60 cases simply drained, 14 died, a mortality of 23 per cent. of cases so treated. I may say, however, that a number of these cases were operated on in the presence of general peritonitis in which the incision was a dernier resort. The durations of the disease in these 14 fatal cases treated by simple incision without removal of the appendices were: 3 days' duration, 2 cases. I case. 45678924 |