ON READING HARRISON'S PRINCIPLES OF INTERNAL MEDICINE FOR THE LAST TIME

CHAPTER 12 ABDOMINAL PAIN

THIS CHAPTER BROUGHT TO MIND my triumph as a third year medical student. An elderly lady was admitted to the hospital and was thought to have gastroenteritis. I was assigned to her case. Armed with a 1960 edition of Sir Zachary Cope's '"Early Diagnosis of the Acute Abdomen," I evaluated and examined her and discovered she had a bowel obstruction from an incarcerated femoral hernia. She was whisked to the operating room. I saved the day. I was celebrated. Cope's book was great and I continue to read it. It is somewhat out of date though newer versions exist. Don't prescribe turpentine enemas as they did in his time. But the clinical descriptions are excellent.

We now have ultrasounds, Cat scans, HIDA scans, laparoscopy. All make a diagnosis more accurate. When I was a medical student it was said that if a surgeon did not remove a normal appendix fifty percent of the time, the surgeon was not aggressive enough and was missing diseased appendices. The CT scan has changed that. I read that on occasion now some cases of appendicitis are treated with antibiotics. That is difficult for me to accept. 

I had my appendix removed when I was six years old. I was told it was appendicitis. I would like to get the path report from 65 years ago. All I can remember is the smell of ether. You never forget it.

I worked at Old Grace Hospital (built in 1880) in Detroit  as an x-ray orderly before I went to medical school. Harry Houdini died there in 1926 of a ruptured appendix. He needed a more aggressive surgeon. His was one of the fifty percent that should have been removed more quickly. Ours has never been an exact science.

Old Grace was torn down and became a parking lot in 1979, but before then a yearly seance was held to communicate with Houdini for he said that if anybody could escape the grave and come back it would be him and so for decades on October 31 the faithful met at Old Grace Hospital.No word on the outcome.

Speaking of appendicitis. When I was a fellow at MGH we were taught that when a patient goes into kidney failure after surgery it usually means a surgical mishap which forty years ago meant re-exploration. I consulted on a patient who soon after surgery went into kidney failure. I told a famous surgeon-the doctor who achieved international fame for successfully reattaching a young boy's severed arm, that a patient in kidney failure after surgery must return to the OR. His name was Dr. Ronald Malt and his influence remains with me to this day. 

I told him that the surgeon whose patient was in kidney failure should go back to the operating room, something was wrong.

He said to me, "Spoken with the blind courage of the non-combatant." But he did admit I was correct and the situation was remediated.

This experience came in handy several years later. I received a call from a nurse whose daughter was admitted for an acute appendicitis and taken to the operating room earlier that day. By the evening she was not doing well. The nurse called me and explained the situation. I did not go to that hospital often, though I did have privileges there. I drove in and examined the young woman. She was pale, and in pain. Her blood pressure was low and her labs revealed an acidosis, kidney failure and an elevated white blood count. I called the surgeon and said he must reoperate, the girl was going into shock. 

It was now near midnight. I got some pushback. I told the surgeon that if he did not go back in and see what was going on, I would transfer her to my hospital and have a surgeon re-explore her abdomen.

Reluctantly  he took her to the operating room and in the morning she was dramatically improved. Her acidosis, white blood count and kidney failure were resolving or coming back to normal.

I asked the surgeon what he found.

"Nothing," he said.

"Baloney," I said but I really meant bullshit.

The young woman did well and years later would become a friend of my daughter-in -law.

That's when its nice to be a doctor.