OF OBSTETRICS Gynecology and Pediatrics PUBLISHED BI-MONTHLY WM. FRANCIS HONAN, M. D., EDITOR VOL. XXV. 1903 A. L. CHATTERTON & CO. 97 and 99 Reade Street, New York City JOURNAL OF OBSTETRICS, EDITOR, WM. FRANCIS HONAN, M. D., NOTE TO CONTRIBUTORS AND SUBSCRIBERS. 1. All articles or communications to this journal should be exclusively for its pages. 2. This Journal is published for its subscribers only, and has no free list. Sample copies are never sent. Subscriptions are not discontinued until so ordered. What is not right will always be made right cheerfully and without question. A. L. CHATTERTON & Co., Publishers, New York. No. I. JANUARY, 1902. VOL. XXV. APPENDICITIS COMPLICATING PREGNANCY AND PARTURITION.* BY B. FRANK BETTS, M. D., PHILADELPHIA. It is reasonable to assume that the frequency with which appendicitis is met with in the human race may be accounted for by the fact that the organ involved is vestigial, and slowly undergoing atrophic changes. Its low grade of functional activity conduces to a diminution in its vascular and nerve supply. This leads to atrophic paresis, sluggish metabolism, and tissue degeneration. Disease follows closely upon such conditions, for when the vitality of any organ or tissue of the body is below the standard of health, the invasion of pathogenic bacteria is much more likely to be followed by the development of specific morbid effects. The appendix is so closely connected to the intestinal canal as to favor such an invasion. Under these circumstances the secretions become vitiated, peristalsis becomes defective, and the most favorable conditions exist for the development and multiplication of bacteria. As a result inflammation ensues, followed by cicaRead before the Homeopathic Medical Society of Pennsylvania. 132224 tricial stenosis or the formation of appendicial concretions, either of which may block the lumen of the organ as effectually as a kink or twist in its long axis. From defective circulation and enervation a "vicious circle" is formed that ends in ulceration, necrosis of tissue, abscess, or gangrene,. with a possible liberation of septic matter within the peritoneal cavity and general septic peritonitis. From this standpoint we account for the observation that appendicitis is met with less frequently in women than in men, by the fact that the appendix has a better vascular and nerve supply from its close proximity to the tubo-ovarian structures. This anatomico-physiological advantage accounts for the increase of appendicular pain during menstruation. We know that primary (acute) appendicitis rarely develops in the early stages of pregnancy, for the reason that increased metabolism in all parts of the body is characteristic of this period. On the other hand, post-partum or child-bed conditions conduce to a lowered state of vitality, with a well-known defect in the power of the organism to resist the influence of microbic invasion. A review of the literature of appendicitis complicating pregnancy and parturition confirms these conclusions, and while the primary (acute) disease rarely develops during the early stages of gestation, it seems probable that when such cases do occur the increased metabolism will supply advantages from which we may expect better results, from a judicious course of homeopathic medication, than can be hoped for at the later stage of gestation, when physical influences, causing a displacement of the viscera, increase the defective metabolism. That medical treatment has an important sphere of usefulness in the successful management of this disease during the early stages of gestation may be illustrated by a report of the following case. In October, 1901, the writer was summoned, in consultation, to southern New Jersey, to see Mrs. M., who had just entered the sixth month of pregnancy. She had suffered from several attacks of severe pain in the region of the appendix, with occasional vomiting, loss of appetite, diarrhea alternating with constipation, and fetid breath. She was pale and emaciated, and there was sensitiveness over the right iliac region, but no evidence of tumefaction, either from vaginal or external palpation. Bryonia was prescribed, but recognizing the necessity for prompt surgical interference, if satisfactory results were not soon obtained, arrangements were made for a daily report of the progress of the case. Under this treatment, with a restricted diet, a prompt result was obtained, so that the necessity for surgical interference was obviated. A communication from her physician, Dr. Geo. W. Fitch, dated August 30, 1902, informed me that the confinement was perfectly normal, and that during the later stages of gestation there were no further attacks of severe pain, and no complications before or after delivery: only a slight tenderness remains in the region of the appendix. This patient never had any symptoms of appendicitis before she became pregnant. Mortality. Appendicitis complicating pregnancy has always caused a mortality much greater than that reached in the class of cases not so complicated. Vinay refers to a death rate of 10 out of a total of 32 cases, a percentage of 38, which is certainly double that of ordinary cases. Another author collected 22 cases occurring in pregnancy with a mortality of 30.4 per cent. It does not seem probable that any part of this mortality can be attributed to gestation as a prime factor per se in the development of the disease, but rather to the mechanical influence exerted by the gravid uterus upon purulent collections, surrounded by adhesions, remaining after previous, perhaps unrecognized, attacks of the disease. A sudden recrudescence in these cases is a relapse, chronic inflammation having been overlooked, or a purulent accumulation having been unrecognized. While pregnancy may therefore play no part in the development of appendicitis, it renders the prognosis, respecting the life of both the mother and her offspring, much more serious when such a complication has already developed; and from this fact we deduce a strong argument in favor of the most careful and efficient treatment of the disease before marriage or the occurrence of pregOne of the most serious complications to be met with in pregnancy is an appendicial abscess, the result of a previous, acute attack of appendicitis, for in the whole domain. |