American College of Physicians: Internal Medicine — Doctors for Adults ®


The wisdom of teens

From the October ACP Hospitalist, copyright © 2011 by the American College of Physicians

By James S. Newman, FACP

Three years ago, my oldest son Eric came home from school with abdominal pain. Good father that I am, and suspicious of malingering, I told him he would be fine unless he developed right lower quadrant pain. My younger son, Elliott, listened avidly, perhaps in the hope of improving his own repertoire of maladies. Several hours later, Eric called me claiming he did in fact have right lower quadrant pain. It wasn't till early in the morning when I checked him—and found him febrile, diaphoretic and guarding. I realized that both my diagnostic and parenting skills needed sharpening.

Being a better historian than a paternal unit, I pointed out that this was McBurney's sign, first described in 1889 as a marker for appendicitis. Surprisingly, Eric showed little interest in this historical tidbit. Ninety minutes later, his necrotic—but luckily not perforated—appendix was out. He had, in fact, had right lower quadrant pain.

Photo courtesy of James S. Newman.

Photo courtesy of James S. Newman.

Jean Fernel, who studied and practiced medicine in France in the mid-sixteenth century, is believed to have written the first description of appendicitis with perforation in his Universa Medicina. The first report of an appendectomy, meanwhile, came from Claudius Amyand, a refugee surgeon of the English army and founder of the St. George's Hospital in London. Amyand performed an appendectomy in 1735 without anesthesia or antisepsis, in order to remove the perforated appendix of an 11-year-old boy. (from Classic Descriptions of Disease by Ralph H. Major, 1978)

In mid-August, my family and I were returning from a whirlwind road trip from Minnesota to New York City. We saw several great shows, and I had the pleasure of speaking at Montefiore Hospital. We consumed a variety of culinary delights, from street vendor food to that Dim Sum delectable, chicken feet. It was little surprise, then, that after such a gastronomic marathon I had abdominal pain and diarrhea. At least it did not hit until I was home from the 22-hour drive. Doing my best to ignore my symptoms, I waddled to the office to face a scary mound of paperwork. I could not think straight, but assumed I must just be tired from the trip.

It was September 1942 on the submarine Seadragon, and 23-year-old Pharmacist's Mate Wheeler B. Lipes was faced with a dilemma. A 19-year-old crew member, Darrell Rector, was complaining of abdominal pain. The crewman had a rigid abdomen and rising temperature, and was getting worse. It was appendicitis, no doubt. Faced with the potential death of his patient, and with no doctor on board, Lipes opened Rector's abdomen. At first he could not find the appendix, and wondered what he was doing wrong, but with exploration he found it deep inside—and gangrenous. He tied off the appendix, made a cut, cauterized the stump with phenol, then neutralized the phenol with torpedo alcohol. There was no penicillin available at this time, yet the patient survived. The story of this dramatic surgery, performed beneath the sea in the middle of a war, won a Pulitzer Prize for a writer, fame for a Pharmacist's Mate and a five-inch necrotic souvenir for a crewman. (Chicago Daily News, Dec. 14, 1942)

I gave up on the paperwork and stumbled home. Despite the post-trip mayhem in my house, I crawled into bed, hoping to sleep it off. Elliott, now 14, came into my room and told me I didn't look too well. He leaned over me, then poked me in the right lower quadrant—just as he'd seen me do to his brother three years earlier. He was quite clear about his diagnosis: “Dad, you've got appendicitis. Better go to the emergency department.”

I drove myself to the ED and told them I was a physician with appendicitis. They told me to take a seat.

Leonid Rogozov was going down the road feeling bad. He had sailed in November 1960 to the Soviet Antarctic as the only physician on an expedition to build a new arctic base. It was now several months later; winter had set in and his party of 12 was stranded. Dr. Rogozov was developing worsening abdominal pain, weakness and nausea; soon the mid-epigastric pain shifted to his right lower quadrant. His temperature was 37.5 degrees. He diagnosed his own appendicitis, but realized that flying was impossible due to snow storms. As he got worse, he decided he had only one option: to operate on himself. He used local anesthesia and a mirror held by his companions to see where to cut. The surgery took 105 minutes. (BMJ. 2009;339:b4965)

Unlike my historic forebearers, I was not to have a diagnosis without a scan. Despite fever, the dreaded right lower quadrant pain, and a prominent leukocytosis, it was deemed that an image was needed. Luckily, it turned out that the only thing perforated was my abdominal wall, when the laparoscope was inserted. My length of stay was shorter than some television mini-series. I successfully hid my postoperative urinary retention, dribbling out a few cc's hourly to avoid hydronephrosis. I assured the nurse that a bladder scan was unnecessary. By the next day, I was already home, once again enjoying the pleasures of micturition—a true joy to the catheter-phobic. What had I learned from this medical adventure? A bit of historic trivia, not to ignore right lower quadrant pain, and most importantly, always listen to my in-house, teenage diagnostician.

James S. Newman is a hospitalist at the Mayo Clinic in Rochester, Minn. and editorial advisor to ACP Hospitalist.


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