APPENDICITIS MORTALITY AND THE GENERAL PRACTITIONER-A SURGEON'S VIEWPOINT.

BY FRANK D. SMYTHE, M.D.

MEMPHIS.

Surgeon to St. Joseph's Hospital, etc.

THE family physician or medical attendant rendering first service has it in his power to greatly modify if not practically do away with appendiceal mortality. Eliminating the cases not seen by a physician during the first twenty-four hours and the cases positively declining to accept specific treatmentsurgical—a small percentage of cases fulminating will die if not seen at the very outset and subjected to immediate operation. Those declining surgical intervention will also furnish a mortality for which the general practitioner should not be held to account.

Surgical literature affords abundance of evidence in support of the statement that death resulting from appendicitis is extremely rare when patients are operated upon at the outset during the first day, while the infection is confined to the appendix; death rarely occurring when the operation is performed during the quiescent stage of the disease, denominated by some as the period between exacerbations, others as the period between attacks.

Skillful abdominal surgeons lose practically none of the latter class of cases. In acute cases operated upon during the first day, we may expect a mortality of 1 per cent., owing to the virulency of infection, rapid death of the organ, leakage, shock. Shock incident to rupture is so profound in some cases that the patient yields before general peritonitis has had time to develop. Obviously such cases could not be withheld from their approaching visit across the river Styx, even if the surgeon was summoned at the outset with request to come prepared to operate. The laity and many physicians express no surprise at a fatal result following gunshot wounds of the abdomen in a perfectly healthy man. On the other hand, they hold the surgeon not entirely blameless should he lose a case operated upon with

Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 12,1902

perforation and infection of a most violent form in a man diseased from ensiform cartilage to symphysis pubis.

Gentlemen, surgery has not reached that coveted state of perfection, and until it does I beg of you to no longer jeopardize the life of your patient by expecting of us the impossible. Your patient deserves and expects the benefit of an early operation. The same should be accorded him. The most that the surgeon can do is to aseptically, skillfully and quickly perform the operation. The opportunity of doing this at a seasonable hour depends upon the ability of the family physician to recognize the disease early, and his convictions upon the great importance to his patient of an early operation. By early operation, I mean at the outset of an acute attack, or during quiescence in the chronic cases. Practically all cases are seen by a medical man at a time when operation could be performed safely and successfully, resulting in the cure of the patient. Who amongst you would hesitate to use quinin for malaria, mercury for syphilis, antitoxin for diphtheria, sulphur for itch, or pelletierin for tenia, immediately after diagnosis of the respective diseases? I answer, none. Why then delay in having applied the specific remedy in your cases of appendicitis?—a malady almost as prevalent and more fatal than any of the diseases for which we have well-known specifics.

What happens in many cases that are permitted to go three or four days under treatment of ice bags, hot poultices, salts and starvation?-the starvation plan being second in importance to surgical treatment. Whatever is worth doing is worth doing well. A case not treated surgically at the outset should not be treated at all for several days - Ochsner's method. This plan favors the descent of the omentum and fixation of hollow viscera, quarantining the turbulent and virulent microorganisms with their deadly toxins. In the event of the absence of or inability to procure the services of a good surgeon, this plan of treatment has my unqualified endorsement. The mortality attending such a plan of management would be infinitely less than cases operated on by an inexperienced surgeon with untrained assistants amidst unsanitary surroundings. I do not mean to imply that successful surgery is confined to the limits of a great city by any means; some of the very

best work that has been done and is being done in America today is in a small town in Minnesota (Rochester) by the Mayo brothers. They are accomplished surgeons and their equipment is of the highest order. Their results are thus readily explained.

Delay is responsible for fever, sapremia, frequent pulse, exudation, adhesions, pus formation, ulceration, perforation, peritonitis and death; or abscess formation, gangrene of the appendix, cecum, mesentery, even the abdominal wall, chills, fever, septic pyemia. The abscess pointing upward in the loin, often mistaken for perinephritic abscess; in Scarpa's triangle, in the pelvis, and recognized as ischio-rectal abscess; retroperitoneal, rupturing into the pleura, being recognized as empyema; not infrequently into the bowel, producing colitis and hepatic abscess, death from exhaustion, septicemia, and pyemia. The above-mentioned pathological conditions bear testimony and present argument that would convict any physician of having failed to do his duty to his patient provided he permitted such sequele to develop without a protest on his part to the patient.

I quote from that distinguished practitioner and gifted author Dr. James Tyson, of Philadelphia, Professor of Theory and Practice of Medicine, University of Pennsylvania, who in a paper before the medical section at the Saratoga meeting of the A. M. A., said: "In all cases in which the actual and undoubted existence of appendicitis can be shown, laparotomy should be done and the appendix removed if the services of a competent surgeon can be procured. In making this announcement I shall probably surprise some of my medical friends, even a few surgeons. But I beg you will note again what I have said the appendix should be removed in all cases in which the undoubted presence of an appendicitis is established and the services of a competent surgeon can be procured." Authors of modern text-books on the practice of medicine, and the leading men doing general practice, no longer provide a scapegoat for the least delay after diagnosis of appendicitis has been made in summoning to the patient's aid the services of a good surgeon.

Surgeons have labored long, earnestly, ably-yea, pathetic

ally-toward the accomplishment of this end. To Dr. John B. Deaver more than any one man is credit due the present status of appendicitis and our knowledge of its pathology.

Observation upon the operating table time and again has convinced me of the utter uselessness of medical treatment so far as the prevention of fatal complications is concerned. Physicians persisting in such a plan of management will give their reasons, or a medical mystery remains unsolved.

About one year ago I reported before the Mississippi State Medical Association forty-nine cases of appendicitis that I had operated upon, with observations. Forty-one of those cases recovered and eight died. Of those dying seven of the eight were acute gangrenous cases. The operation having been delayed up to and after the third day. General peritonitis existed at the time of operation in all cases. The other death

was that of an old man that had been suffering for two weeks. The right half of his abdominal cavity filled with pus. The abscess was incised and the patient died from sepsis and exhaustion two weeks after operation.

Since that report I have operated for appendicitis forty-four times, with the result that forty of the patients recovered and four died. Three of the deaths occurred in cases of acute, gangrenous appendicitis; the operation had been delayed until infection was wide-general peritoneal. The other case dying was an appendiceal abscess of long standing that had produced septicemia before a surgeon was called. It was incised and drained, but with little hope of improvement, as the patient had advanced too far under the influence of sepsis.

Out of the forty-nine cases reported over a year ago, thirtyeight had experienced former attacks; of the forty-four recent cases, thirty had previously suffered from appendicitis. Sixtyeight cases, out of a total number of ninety-three cases reported, were of the chronic or recurrent variety; twenty-five of the cases were seen during the initial attack. The sixty-eight cases had been reported cured by medical treatment, some of them many times, by their attending physicians, in former attacks. No relapse since the removal of their appendices. The time had been when any of the four of my cases that died could have been saved by an operation. A fatal mistake

was made in all of those cases, either by the physician in failing to advise operation at the proper time, or the patient in not heeding such advice when given. The recognition of that time by the family physician is an important duty, and in the prompt and fearless discharge of that duty lies our only hope of materially reducing the mortality rate of appendicitis.

AN ADDITIONAL ARGUMENT

FOR EARLY OPERATION IN APPENDICITIS.*

BY BATTLE MALONE, B.A., A.M., M.D.

MEMPHIS.

Clinical Instructor in Minor Surgery; Demonstrator of Operative Surgery, Quiz Master to Chair of Surgery; Memphis Hospital Medical College.

In this day, when surgeons are reporting cases of appendicitis, some thirty, some sixty and some an hundred fold, I trust that you will not consider me the unprofitable servant and bid me depart into outer darkness for taking up your time to listen to the report of a single case.

American surgeons are almost unanimously agreed that every case of appendicitis should be operated upon at the outset of the attack. If this could be done the mortality of the disease would be less than 1 per cent. All realize that a large proportion of cases apparently recover with little or no treatment, but the insurmountable difficulty is in differentiating at the beginning of the attack between simple catarrhal appendicitis, ulcerative appendicitis and infectious appendicitis. Murphy says that we can positively determine when appendicitis is present, but that in most cases we can not say how extensive, how dangerous and how far-reaching the effect of that appendicitis may be. Mynter says, "In regard to the question whether an appendicitis will perforate, we must fairly acknowledge that we are in many cases unable to forecast the future. The diagnosis is easy enough if we wait till the disease has developed and the symptoms of a local abscess or diffuse peritonitis are present, but we have then lost the favorable time for an operation, and will lose a number of our patients who by an earlier operation surely would have recovered."

* Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 12, 1902 Vol. 23-2