Grand Senior Counsellor of the Medical Association of the State
of Alabama; Fellow of the British Gynecological Society;
Vice President of the Southern Surgical and Gynecological
Society, and President of the Tri-State Medical Society of
Alabama, Georgia and Tennessee.

THE fact that physicians take the stand that operative interference is called for only in exceptional instances where the disease advances to suppuration, gangrene and perforation, makes the treatment of appendicitis a never-ceasing controversy. Hence my excuse for taxing you with another paper on this now everyday subject, reporting a few illustrative cases that have come under my observation, hoping thereby to add what I can to harmonize the differences between the physician and the surgeon on this, the most frequent and important intra-abdominal lesion of the present day. The main point at issue between the physician the

upon a perfect diagnosis. their differences of opinion as to where the medical treatment should end and where the surgical treatment should begin. A word on the history of appendicitis. Is it not strange, in

This, too, accounts in a measure for

*Delivered before the Tri-State Medical Society of Alabama, Georgia and Tennessee; Nashville, October, 1897.

deed, that the true pathological knowledge of appendicitis which we now possess was not described prior to the year 1886? It was in that year that Dr. Reginald Fitz of Boston published his paper on "Pericecitis." He then outlined in a very accurate manner the true pathology of the disease now so generally known as appendicitis. However, it was in 1866 that Dr. Willard Parker of New York first commenced the practice of opening what, was known as perityphlitic abscesses. Dr. H. B. Sand was a coworker with Dr. Parker, and practiced this treatment of these abscesses in the region of the vermiform appendix. It is quite

clear that nothing of material worth has been added to our pathological knowledge of appendicitis since the publication of Dr. Fitz' paper in 1886. It was left, however, for Dr. Sands to perfect our knowledge of the treatment of this affection when he successfully operated and removed the appendix from a boy, a patient of Dr. Simon Boruch, in 1888. The first case of perforating appendicitis that came under my observation occurred in 1879. The patient was a female 45 years of age. I had in consultation the then best known gynecologist in Georgia. The diagnosis of typhlitis was made, and the treatment consisted in the administration of laxatives and liquid food. The abscess finally ruptured in the right iliac region, but the patient died some months later from peritonitis. In 1886 I treated two cases of appendicitis, one the wife of a physician, aged 25 years, the other a male, aged 22 years. In both of them there was a distinct point of tenderness and swelling in the region of the caput colli. I had not seen the paper of Dr. Fitz (1886) nor had I heard of the case operated on by Dr. Sands in 1888. I administered laxatives and removed a few drachms of bloody serum in each case with the small needle of the aspirator. The male patient had only one attack and recovered. The physician's wife had three attacks, but has had no return of the disease since 1886. Both of these patients are still living.

.

Now, according to my experience, from knowledge obtained from examinations of diseased appendices and the post-mortem table, I think we are quite a long way from knowing the true and primary cause of appendicitis. It is most generally thought to be caused by interference with the proper drainage of the tube, and I am quite willing to acknowledge that interference with drainage occurs in most of the cases of appendicitis; this accounts

for the pain that radiates from the solar plexus, and finally settles down in the region of the caput colli. (But these are the results of appendicitis.) It is plain to be seen how mechanical obstruction may cause distension, pain and fatal perforation, but according to the statistics of most operators foreign bodies are rarely found in the appendix.

and 16

The Medical Record states that autopsies upon 400 persons dying with various diseases showed fæcal concretions in the appendix in only 10 per cent. In Renvier's collection of 454 autopsies after appendicitis there were found 179 concretions foreign bodies in the appendix. Hawkins examined 60 fatal cases of appendicitis and found no foreign body in any of them. Fits analyzed 300 cases and found concretions in 5 per cent of them. In the course of his discussion on two papers on appendicitis, one by Dr. Brokaw of St. Louis, and the other by read before the Southern Surgical and Gynecological Association on this floor in 1896, Dr. Gaston of Atlanta asked

myself

whether

cases on

we found any foreign bodies in the appendix in the which we had operated. Our answers were that we

found no strictly foreign bodies in the appendix.

I am

inclined to the opinion that, even when small foreign bodies are found in the appendix, this does not prove that such foreign body was the primary cause of the inflammation in the appendix. I am quite sure that there is something yet to be learned in the etiology and pathology of inflammations about the caput colli, involving the appendix-that there are many cases of appendicitis, and even so far advanced as ulceration of the mucous membrane of the intestine and the appendix that go unrecognized until the tube accidentally becomes obstructed, thereby interfering with proper drainage when the rational and physical symptoms of appendicitis are developed. In fact, I am almost persuaded that there is a special germ that produces most attacks of appendicitis and that the contents of the intestine become concretions, and they, as well as foreign bodies, become lodged in the tube on account of lessened normal intestinal secretion and contractility of the muscular walls.

However this may be, the question that most concerns us as physicians and surgeons and humanity in general, is, how to treat

the disease.

I will refer to a case that I will use to illustrate my idea of

treatment of the mild cases. Female patient, 16 years of age, taken with pain in the region of the solar plexus, and within 24 to 48 hours settles down in the region of the appendix. Temperature 99°, pulse 80. This is the first attack, and the bowels respond promptly to calomel and salines, and the pain is completely subdued with gr. doses of morphia. At the end of two weeks, if there is still some tenderness in the region of the appendix, I advise operation; but if there is complete recovery I wait for a second attack, and if this is a mild one I advise operation so soon as the acute symptoms have subsided. This is the exact plan that I think best to follow, although I admit that there is danger all the time of perforation and a fatal result. I place against this, however, the fact that many cases of mild appendicitis recover from first attacks (Dr. McGuire says half of them recover from first attack), and may remain well. Operations done for the removal of the appendix under the circumstances that I mention are almost universally successful, the mortality not being more than one per cent.

I will now refer to quite a different variety of appendicitis, when the attack is sudden and severe and demonstrated by high temperature and rapid pulse; perhaps these symptoms have been preceded by a chill, respirations frequent, and the gray, anxious expression of sepsis. The only chance for life is by an immediate operation. Such cases as these bring fright to the friends and medical attendants, and have caused many surgeons, including myself, to write in former papers that an operation should be done in all cases just as soon as the diagnosis has been made. Such cases as these are sometimes difficult of diagnosis and may be mistaken for intestinal obstruction.

I mention the following case to illustrate: I was called by Dr. J. J. Harlan to see such a case, where the pulse of the patient, a male adult,was 80 to 90, temperature 100°, distension of the abdomen, vomiting, and the bowels obstructed. After 24 hours the bowels moved freely and the symptoms were somewhat relieved. The pulse and temperature were lower and vomiting much better. We made the mistake of waiting for further developments, and at the end of 24 hours longer he was evidently in articulo mortis; no operation was done. At the autopsy, the appendix was found low in the pelvis, gangrenous, and ruptured, quite a quantity of stinking pus in the abdominal cavity, the intes

with

I

To

tines everywhere bound together by adhesions, two perforations
in the intestine, and two much constricted points, as though a
small rope had been tied around the intestine and removed.
will say that in a general way I usually defer the operation until
the bowels have been moved by first administering a few small
doses of calomel and following with a saline purge. In this class
of cases I believe it the duty of the surgeon to operate in every
instance, no matter what the physical condition of the patient may
be, unless he knows that death is inevitable from sepsis.
operate in the class of cases just mentioned and merely irrigate
the abdominal cavity might save a few. In some cases the opera-
tion could be done under local anesthesia. I would warn the
surgeon of the danger of a prolonged cperation under general
ancesthesia on a patient who has a greatly distended abdomen,
gas and fluids. I have frequently been asked by the laity if
the operation for appendicitis was not a very dangerous operation.
I entertain the idea that the most frequent cause of death in ap-
pendicitis, whether an operation is done or not, is septic infection.
This condition is most often the result of delay in operating.
From observations made of my own cases, besides those drawn
from many other operators, I have arrived at the conclusion that,
in all cases of appendicitis attended with formation of pus, rup-
ture and gangrene, the operation should be performed just as soon
as the diagnosis can be made. Mr. Treves has advised that the
operation may be delayed on the ground that the fluid will come
nearer to the surface. I think, however, that there is much dan-
ger of its burrowing in any, or many other directions across the
peritoneal cavity, as was clearly demonstrated in my cases Nos.
VI and VII. The former lost his life and the latter only made a
harrow escape by delay in operating.

I will now give an analysis of the following cases, fourteen in rumber, in all of which the appendix was ruptured and gan

grenous.

CASE I.—Mrs. R., aged 40 years. Dr. A. T. Bryant had attended this woman for four days. She was taken with pain in the stomach, accompanied by vomiting, which finally became localized in the region of the appendix. Her pulse was 130, temperature 1021° F. The operation consisted in opening the abdomen and the region of the appendix. The appendix was found to be ruptured and gangrenous. Its removal was followed by irrigation and drainage. Recovery.