HOW SHALL WE TREAT APPENDICITIS. Professor of Surgery and Clinical Surgery, Vanderbilt Medical Dept.; Medical men, both internists and surgeons, are agreed upon the fact that many cases of appendicitis offer problems in diagnosis that may, and do, puzzle the most experienced practitioners. When, however, the symptoms are so pronounced that the disease can be recognized, they are still far from having a crystallized opinion as to the proper line of treatment to be adopted. With the hope that I may be able to aid in arriving at a correct conclusion as to the proper conduct of such cases, it is my desire to present for your consideration a report of the cases of appendicitis that have come under my care during the year of 1914. By the aid of this I hope to show what is the safest method of treatment of such cases. During the year of 1914 I had referred to me:- 2 Cases were dying of peritonitis when I saw 66 Cases were acute, and of these four died. The 4 On the first day. 19 On the second day. 1 On the ninth day. Those that died after operation were seen, one on the seventh day, one on the eighth day and two on the fifth day. These four cases were all suffering with general peritonitis; though not deemed moribund at the time, they were submitted to operation. The gravity of these conditions, however, were recognized both by their friends and by the consulting physicians. The two who were moribund when seen by me, each had been sick five days. Before taking up the treatment of this disease it may be well to consider briefly the pathology of appendicitis. The inflammatory condition begins in the mucous membrane and may be diffuse, affecting it in its entirety, or it may be circumscribed and expend its force upon a small part of it. The inflammatory process may subside without involving the muscular and peritoneal coats of the vicsus, or it may, and more usually does, affect one or both. It may end in resolution, or it may proceed to any degree of destruction up to complete necrosis of the whole organ. The chief symptom, pain, unfortunately is not a sure index of the destructive force of the disease and hence cannot be relied upon as a guide to treatment. The pain may be due to different causes. It may come from obstruction of the outlet of the appendix by a kink or lith, or by the inflammatory swelling with distention of the lumen of the organ beyond the point of obstruction; or it may be due to the irritation of the poisonous material within the appendix, or it may be due to the inflammation extending to the peritoneal coat. If the pain is to be explained by any of these causes, we would not expect it to be very severe unless the appe..dix was in proximity to the parietal peritoneum, since we know that the serous lining of the abdominal wall is the only very sensitive part of the peritoneum. Clinical experience bears out our anticipations, since as a matter of observation the pain in any stage of appendicitis is far from agonizing. Tenderness varies very much, depending upon the situation of the inflamed organ. If close to the anterior abdominal wall, it may be very marked even when the pathology is not great, and on the other hand, if it be deeply placed underneath gaseous dilated intestinal coils, there may be but little tenderness. Rigidity of the overlying muscular wall, while usually of great diagnostic value, sometimes fails us if we attempt to use it as a guide to therapeusis, since, like pain, it is influenced by the position and condition of the inflamed structure. At times, it will be marked, with no great pathology existing, and again it may be almost, if not quite, absent when the appendix is actually necrotic. Fever, too, canot be relied upon as an index to therapeutic measures, since it is the experience of every practi tioner to see severe cases in which there is but little, elevation of temperature. if any, A leukocyte estimate may help in diagnosis, but the majority of practitioners are not prepared either by experience or training to make an efficient blood examination, and it is of little value as an outline to treatment. The symptoms I have mentioned, taken as a whole, may form a picture sufficiently plain for diagnostic purposes, but it cannot be relied upon to inform us in regard to the progress of the hidden pathology, as many men have found to their chagrin. That the disease is essentially a surgical affection, is admitted by all authorities, and this is further proven both by its pathology and its course. No medicines that we possess have any power to stay or control the progress of the affection. This does not mean that there is no medical side to appendcitis. The general practitioner is usually the one first to see the sufferer, and upon him devolves the responsibility of making the diagnosis and outlining the treatment. He is looked to for relief from the suffering, and he is the one whose duty it is to protect the patient from the unwise doping and purging, insisted upon by the family and friends. He, too, is the counsellor, upon whose advice the patient and family depend, in determining whether a surgeon shall be called or not. The time has now arrived when he must bear the censure of the public if he calls the surgeon too late. Every surgeon, again and again, has had the painful experience of finding himself unable to protect the family doctor from the outspoken blame of "too late." In many cases the delay is due to the wishes of the friends, but these same friends are only too glad in times of disaster to shift the responsibility to the shoulders of the medical adviser who has not been sufficiently insistent. More and more is the public learning that the disease is surgical, and requires early operation. Less and less are they fearing and combating what they are learning, viz., that appendectomy is a procedure almost without danger if done in the early hours of the affection. What then is our duty when we have made a diagnosis of appendicitis? Let us for a moment look at the results in the cases I have already set out. All those operated upon while not in an active state recovered. All those subjected to operation during the first two days of the disease recovered, without drainage or morbidity, and were out of bed as early as those so treated when in the chronic state. Of those operated upon after forty-eight hours, twenty-nine required drainage and were in bed from fifteen to thirty days, while those that died were not seen by the surogeon until after the fourth day. In each case the hope had existed that a medical treatment would have carried them safely through. If we turn to the accredited authorities who have written upon this subject, we find that their teachings accord with. the results that I have reported. Statistics gathered from all sources further prove that cases in the chronic state or cases in the first day of the disease, equally, if operated upon, have practically neither mortality or subsequent morbidity, while with each day of delay thereafter the danger increases. Why delay? It is equally well known, and statistics have proven that the disease when not treated surgically has a mortality variously given from 8 per cent to 15 per cent. If we accept the smaller number, that is, a death rate of eighty (80) in a thousand when treated medically, as against one in a thousand if given the benefits of surgical treatment, it is difficult to understand why a delay in the choice as between these two should ever occur. The explanation is found in the optimism and hope that ever exists in the human breast. Unless the subject is presented in a firm, cold, matterof-fact manner, so that the dangers are well to the fore |