APPENDICITIS- 3

CHAPTER III

    Etiology: To understand the cause of appendicitis we must go back to the beginning, and when we do we find that it starts just where all diseases start, namely, where health leaves off! When the laws of health are broken for the first time, it can be said that the individual has started on the road of ill health. How fast he will travel and just what will be the character of the disease he meets with will depend upon his constitution, inheritance, environment and education. I do not mean by education, school or book education; I mean intuition--that knowledge which evolves from home life and habits. I mean, has he any self-discipline? Does he know anything about self-denial? Has he any conception of a control higher than impulse? Has he been brought up to know that there is a limit to the gratifying of wants and desires beyond which, if he goes, he must make good with laws that are as exacting as they are invariable? Does he know that nature shows no favoritism? Does he know that there are laws regulating his intercourse with men-- with everything--that exact absolute justice from him? And that, if he takes advantage of weakness or ignorance because he can, or if he secures an advantage through credulity or trickery, he must settle for the crime before a judge who is absolutely just! If he has this education, which is a constitutional ingrafting from the mother's blood, fructified by a like potential father, he will be almost immune from all diseases. This is an education that can not be secured unless the individual has the prenatal and environing influences to differentiate these static attributes of his nature, and, if he has, the result will be that all these qualities will come to him because "like attracts like." In an atmosphere where others attract evil this individual attracts good. The same is true on the physical plane. Those who have diseased bodies always have disease making habits, hence they attract from a given environment all the disease making impulses, while those of healthy bodies have health imparting habits, and attract from the same environment the health impulses for which they have an affinity.

    The constitution, inheritance and education of all mankind will vary from the highest to the lowest types. As we go down the scale from those with ideal physical and mental health, we see man becoming more and more the victim of disease.

    It is no uncommon thing to find people of seeming intelligence who appear surprised when told that they have brought upon themselves such a vulnerable state of health from wrong eating and care of their bodies that they are in line for appendicitis, pneumonia, typhoid fever, bowel obstruction, or blood poisoning. In such types blood poisoning would surely follow a complicated fracture of a bone--a fracture where the ends of the bone cut through the flesh causing an open wound.

    Pregnant women belonging to this class go into confinement with their blood so heavily charged with the by-products of an imperfect metabolism that they are very liable to have septicemia.

    People who think they must have " three square meals a day" must have catarrh, rheumatism, tonsilitis, quinsy, pneumonia, typhoid fever, and all sorts of bowel trouble including appendicitis. Why! Because three meals a day consisting of bread, potatoes, eggs, meat, fish, butter, milk, cheese, beans, etc., overwork the metabolic function and as a consequence organic functioning is impaired, cell proliferation falls below the ideal, bodily resistance falls lower and lower, the intestinal secretions lose their immunizing power more and more, until at last the body becomes the victim of every adverse influence. At first fermentation--indigestion--shows occasionally; the intervals between these attacks of acid stomach, or fermentation, grow shorter and shorter until they are of daily occurrence; accompanying this fermentation there is gas distention of the bowels, and this inflation in time interferes with their motility and weakens them so that sluggishness is succeeded by obstinate constipation.

    Every step of this evolution shows an increasing toxic state of the fluids in the bowels. After constipation is established the efforts at securing evacuations are of such a nature as to irritate the cecum. Drugs to force movement cause painful distentions of this portion of the bowels. The drugs stimulate peristalsis of the small intestine; each wave from the small intestine breaks on the walls of the cecum, for the colon is loaded with fecal accumulations so that the onrushing contents of the small intestine can not be received by the colon; hence the force of the whole peristaltic impact is spent on the cecum, which must endanger the integrity of the mucosa as well as the musculature.

    This point of the bowels, the cecum is more endangered from diarrhea than any other. The toxic ptomaines are especially liable to create a local infection if nothing more.

    This state of the intestines--toxic state--is a constant menace to health; in fact the organism is heavily taxed to maintain its defense.

    The overcrowding of metabolism, as explained above, the chronic constipation and toxic bowel secretions, I recognize as the chief factors--the necessary and leading factors--in the building and maintaining of that constitutional state which I am pleased to denominate Constitutional Catarrh. When this state is established, it can be said that the individual is ready to develop any phase of disease that circumstance, accident, or caprice of fortune or environment may offer.

    The constant presence of gas in the bowels becomes more and more menacing to the cecum as the constipation increases. The filled-up condition of the bowels--the colon and rectum--prevents the easy passage of gas from the bowels, hence it accumulates in the ileo-cecal region and keeps the cecum distended.

    The constant dilating of the cecum from gas accumulations and the forced dilations from diarrheas made either from drugs or irritating foods, must not only damage the cecum but the appendix as well; for the appendix opens into this part of the intestine and it is reasonable to believe that it suffers distention from gas and that toxic secretions are driven into it. When its function is not interfered with by an unusual pressure as from constipation, no doubt it can empty itself and does do so.

    When it is understood first of all that appendicitis--the inflammation known as appendicitis-- is a local manifestation of a general or constitutional derangement, the cause for this local manifestation may be taken up.

    In order to understand why the disease localizes we must refer the reader to the peculiar anatomical construction of the cecum and the appendix, and their relation to other parts. The cecum is a large, blind pouch, one of the shortest of the several divisions in the continuity of the intestinal canal, which begins where the small intestine ends, and ends where the large intestine begins. Its blind end or pouch is down; this dependent position makes it peculiarly liable to impaction and the injuries which are disposed to come from distention; for, as the colon ascends from its connection with the cecum, the force of gravity must be reckoned with.

    The colon is very liable to be more or less distended with accumulations, and especially is this true of those of sedentary habits, for a call to evacuate the bowels is frequently postponed.

    This postponing of duty to nature has evolved, in all these years of civilized life, a weakened functioning so that man is more subject to constipation than any other animal. The bowels are educated to tolerate a great accumulation and the pretty general habit of taking drugs to force action has grown a weakened state which is the natural sequence of overstimulation and as this has been going on generation after generation it has become more or less transmissible.

    The cecum, situated as it is, must bear the brunt of the evil effects of constipation. When the large intestine is full or distended, as it usually is in cases of chronic constipation, so that nothing can pass out of the cecum this organ becomes a jetty head, so to speak, against which the peristaltic waves from the small intestine break. The full force of the peristaltic waves from the small intestine with its onrush of fluid or semifluid contents subjects the cecum to great distention and strain.

    If there were any way to prove that so-called appendicitis is more common to-day than in former times, it is reasonable to believe that the irritating effect of the pretty general habit of taking cathartic medicine has had more to do with bringing it about than any other one thing.

    Distention, with the straining of the walls from peristaltic onrushes as described above, and the infection that this part of the alimentary canal is subjected to because of the decomposition of food that is going on to a greater or less extent in all victims of constipation, are the causes of inflammation in the cecum. If the inflammation involves the appendix or the cecal location of the appendix, it may be called appendicitis, but the appendix is involved the same as any other contiguous part. Any mind capable of reasoning should have no trouble in rightly assigning the responsibility of this disease, if sufficient attention be given to anatomism.

    There is not any very good reason for one capable of analyzing, to jump at the conclusion that the appendix is the cause of the disease because it is frequently found in the field of inflammation. The same reasoning would make Peyer's glands the cause of typhoid fever.

    The unwholesome condition of the intestinal tract which is the immediate or exciting cause of appendicitis and other diseases peculiar to this location, is brought on by improper life; not one cause, nor a dozen special causes, but anything and everything that break down the general health create this condition; then add the accidental eating of decomposition, or add decomposition, auto-generated, and we have the necessary data.

    The opening of the appendix is so very small that inflammation of the cecum soon closes it and then we have a mucous surface without drainage, which means obstruction--opposition to the requirements of nature--for one of the functions of the mucous membrane is to secrete and this secretion must have an outlet or the part becomes diseased.

    According to the theory of bacteriology a micro-organism is to blame for appendicitis. If this were true it would relieve humanity of all responsibility. There is a disposition on the part of man to shirk responsibility and the germ theory is not the first theory of vicarious atonement that he has spun. Those who wish to shirk all kinds of responsibility by adopting the germ theory and by making micro-organisms the scape-goat may do so, but I would advise all sensible people to keep in mind the following truth: Violated hygienic laws predispose to disease; then, when resistance is broken down, the immediate and exciting cause may be anything capable of laying on the "last straw."

    The micro-organisms are present wherever there is life and are as necessary to life as they are to death.

    Ochsner states that in nearly all instances the disease can be traced to the common colon bacillus, which is always present when the intestine is normal. The three pus cocci are sometimes blamed, and so are the bacilli of typhoid fever, tuberculosis and the ray fungus (so- called cause of lumpjaw).

    Other causes given are: Edema and congestion closing the lumen of the appendix, thus preventing drainage; constipation; digestive disturbances; traumatism; eating too freely while in an exhausted condition.

    "Whatever the predisposing causes may be in any given case, the exciting cause is always some infectious material. The colon bacillus is always present in the lumen of the alimentary canal and, although it is harmless under normal conditions, when these conditions arc changed and there is an abrasion, an abnormal condition of the circulation, or a lack of drainage, it becomes at once actively pathogenic. With a perfectly normal peritoneum a considerable quantity of a pure culture of colon bacilli may be injected into the abdominal cavity without causing any harmful effect, as has been shown by the experiments of Ziegler, but if there is any disturbance in the circulation or nutrition of the peritoneum, the same quantity taken from the same culture will give rise to a dangerous peritonitis."--Ochsner. [This goes back to the constitutional derangement. First of all low resistance, then any exciting cause is sufficient.]

    In studying the cause of organic disease, the first thing to consider is the organ itself. A knowledge of its structure and function will indicate what diseases it is liable to have--what the character of the disease must be.

    Reason would say that an organ can be deranged in two general ways, namely: structurally and functionally. In a structural way it may be impaired either by coming in violent contact with extraneous objects, or it may be crowded or pressed upon by enlarged or displaced associate organs. In a functional way the derangement may be brought about from overwork or underwork. A digestive organ may be overworked by being given too much food, or food of too stimulating a quality; or the over-stimulation may come from poisons coming into the food from without or developing in the food after its ingestion. The bowels may be injured by coming in violent contact with external objects. When this is the cause there will be the history of accident, etc.

    The functions of the bowels are to furnish a dissolving fluid which is secreted by glands situated in their structure and opening into their lumen; besides the secreting glands they are provided with power to excrete and absorb. The organs for the accomplishment of these purposes, like the secretory glands, are situated in the structure and open into the canal. Besides the functions of secretion, excretion and absorption, the bowels act as the great sewer of the body.

    The dissolving fluids, or digestive fluids, have the power to overcome fermentation when the general health standard is normal; when the tone of the general health is lowered these digestive juices are lacking in power; hence they are not able to control fermentation if food be ingested to the amount usually taken in health. The power to oppose fermentation by the digestive juices ranges all the way from nil to the resistance usual to a man of full health and vigor.

    It being the function of the bowels to digest food and overcome fermentation, it stands to reason that to accomplish this function they must be normal--they must have a proper supply of nerve force and the supply of nutrition must be normal or they can not furnish the proper amount and quality of secretions. To have all these needs supplied they must be reciprocally related to every other organ associated with them in the organic colonization which totals a human being.

    On account of the reciprocal relationship between the bowels and the rest of the colony of organs, the bowels must share alike; that is, in the matter of distribution of forces no organ of the body can be favored; all must go up and all must come down together. They must all share alike; hence the bowels have their share of the general tone and, if they are required to do more than a reciprocal amount of the work, it stands to reason that they can not do good work; and, if they can not do good work, the whole colony must suffer in a general way, while the bowels must also suffer in a special way. The function of drainage or sewerage is very important, and the perversion of it brings on much ill health. The principal perversion to the function of sewerage is that of constipation, the location of which is limited to the lower portion of the large intestine, a section of the canal least endowed with digestive and absorptive power.

    The result of overwork is depression--exhaustion--prostration; and what does that mean to an organ? Is it possible for an overworked organ--a depressed organ--an exhausted organ--a prostrated organ--to function normally? Is it reasonable to believe that an organ that is inflamed can function properly? Such questions are absurd, I acknowledge. Questions that carry foregone conclusions on the face of them write the questioner down an ass, which I also acknowledge. But I desire to rebut the inference these questions reflect on me by making a few requests which show that there is a lot of professional reasoning based on that sort of logic which justifies my childish, senseless questions.

    Show me a physician, or if you can not show me one, give me the name of a physician who does not feed children in cholera infantum. I want to know a few physicians who do not feed in typhoid fever. I should like to make the acquaintance of a few physicians who do not feed in appendicitis until the disease is made desperate, and who do not begin to feed long before it is safe to feed.

    In all diseases where there is fever, in all diseases where there is pain, nutrition is suspended--metabolism is stationary. I wish some one would be kind enough to inform me of an M. D. who does not feed patients suffering with pain and fever.

    If the inferences these requests carry are true, has the personnel of the profession any right to treat my questions with contempt and declare that they are childish!

    No! Diseased organs can not function properly and it is absurd, yes worse than that, it is criminal to feed under such circumstances. The result of feeding is the prolongation of disease by building it afresh with every spoonful of food.

    I say that every relapse and every complication that have ever occurred in any disease being treated by any physician from the top to the bottom of the profession' even if the treatment was the very best that could be furnished by the highest skill in any of the drug-systems, if said treatment consisted of drugging and feeding, were brought on by the treatment.

    All diseases of the alimentary canal, not of a traumatic origin or from the accidental or intentional swallowing of corroding chemicals or from the continuous use of drugs on the advice of physicians, come from infection or intoxication. Why not? This is the most reasonable cause, for the fecal matter in health is toxic and it only requires one step further to sufficiently intensify the putrefactive change to create irritation of the mucous membrane. Of course there is a degree of immunization taking place all the time. Many people have themselves inured to the constant saturation of fecal intoxication. It is true they are building a large toleration for that particular poison, but their general vital tone is being lowered continually and somewhere and in some way there is a deposition taking place. In women there may be an old cicatrix in the neck of the womb or a lump in the breast; the circulation has been impaired for several years and now because of the overstimulation that has been going on so long, there is a greatly enfeebled circulation and deposits are taking place. The tumor in the breast becomes cancerous; the scar in the womb takes on malignancy; the arteries harden; the circulation in the spinal cord becomes so impaired that induration is induced followed by ataxia; and other troubles of a like character could be mentioned. These are the most favorable results for, while these cases are winding their weary, sluggish course to the land of rest, there have been many taking the rapid transit.

    I wish to emphasize the fact that one of the constant symptoms peculiar to this class of inebriates is constipation. As a class these people carry very large quantities of fecal matter in their lower bowels. This constantly loaded condition of the lower bowels is relieved occasionally by a sharp, irritative diarrhea, accompanied by nausea and vomiting or not. The diarrhea is often preceded by a few hours of acute pain that causes some talk of appendicitis and operation but, much to the discomfiture of the doctor, the bowels start up and relieve all suffering.

    A few of these cases develop a chronic colitis. The bowel discharges are more or less coated with catarrhal secretion. Not all are constipated; obstinate diarrhea is the character of some; there are here and there a few cases that throw off a membrane two or three times a year, often in appearance like a cast of the lumen.

    Enteritis, entero-colitis and dysentery are different forms of bowel troubles that cause much uneasiness, for it is such a common matter to call everything appendicitis, and if the patient is credulous and gullible he may be operated upon even if his disease is a proctitis or a case of gas in the bowels.

    It is no uncommon thing for a case of obstinate constipation, accompanied by colic, to be operated upon for removal of the appendix if the pain is obstinate and hangs on long enough for the patient to be scared into an operation. The pressure from constipation and the constant strain on the cecum render this particular section of the bowels liable to take on local inflammations.

    The recognized literature of the day attributes all infectious disease to germs or micro- organisms. That all diseases originating in the alimentary canal are due to infection there can be no doubt, and all agree, but I do not agree with the prevailing opinion that germs or micro- organisms are the primary cause of infection, for that theory is not sufficient; it can not possibly cover the ground and account for everything that takes a part in the great array of causations that must be considered. To my mind it would be just as reasonable to say that germs cause health, and I defy any bacteriologist to prove that micro- organisms cause disease any more than they cause health; and if he can't prove that germs are more pathologic than they are physiologic, but does succeed in proving that they are equally important to health and to disease, we can agree to that equal importance and should be able to go on agreeing and declare that if germs are the cause of disease they must also cause health and it is our duty to spend at least a part of our professional time in cultivating health germs. In fact it would be much better to spend all our time in cultivating health germs and insisting on people being inoculated with the serum from these germs so that there will develop such a state of health that the disease germs will have no show.

    How can a sane man forgive himself for advocating inoculation by disease germs to cause immunization when by the use of health germs the health could be built so strong that the pathogenic germs would have no show. If this theory won't work both ways it is a false theory, and professional men, who should be logical if any set of men are logical, should be ashamed to advocate any theory that is based upon a half-truth.

    As I stated the structure and function of an organ point to its possible maladies. The cecum is the gate-way between the large and small intestines. Its function of passing the contents of the small intestine into the large is obstructed much of the time. It is constantly subjected to bruising, pressure, stretching, and obstruction, and is, therefore, more liable to be the seat of local inflammations than any other part of the bowels. Diseases of this part of the bowels are liable to come at any time of the year; but in hot weather the tendency to fermentation is much greater than at other times of the year, and bodily resistance is reduced because of the enervating influence of the heat, of too long working hours, and of too short nights for sleep, and of the ever-present, omnipotent and omnivorous appetite which is taking into the stomach and bowels food beyond the digestive capacity both in quantity and quality; all these join in intensifying the habitual toxcicity of the bowel contents to such a state of virulence that those parts of the bowels already weakened, because of the mechanical injuries before referred to, take on a local inflammation. Diarrhea may be the consequence and the bowels may have a thorough cleaning out and the whole trouble end in a few days. Or the constipation may be of a nature that evacuations, such as the patient has been having, have been passing through the center, leaving a coating on the lumen, but hollowed out in the center. When the inflammation starts causing increased bowel contractions--peristalsis--there is a breaking down of the walls of this fecal ring resulting in complete obstruction. The ineffectual bowel contractions then serve to irritate and inflame the affected part still more. The local inflammation is at first superficial but the increasing toxicity of the fluids that are held on these parts causes the inflammation to take on ulceration.

    The inflammation or ulceration may remain superficial, and be located in the lower portion of the small intestine, then the disease is enteritis. If the bowels are cleared out and the patient's blood freed from intoxication, the attack ends; if not the disease will be called enteritis or catarrh. If the infection is a little greater and extends a little deeper causes inflammation of Peyer's glands then the type of the disease will be typhoid fever.

    Children troubled with constipation will sometimes be taken with fever and pain in the right iliac fossa and, on examination, a fullness will be found; the sensitiveness will not be so great but that an examination can be made and a sausage shaped tumor may be outlined; of course, the disease will be named appendicitis and this is enough to scare a whole neighborhood, and the child will be carted off to a hospital and operated upon for appendicitis.

    If the child is left alone, given no food, and ice put on the sensitive parts if the temperature is 103° F., or hot applications if the temperature is less, the tenderness will probably go away in two or three days; if it does not, an abscess will form and empty into the cecum. If the child is fed, and the tumor manipulated--subjected to unnecessary examinations--the abscess may be made to burrow down toward the groin, which should be avoided for it is a very undesirable complication. The first abscess is typhlitic, the second is perityphlitic. The first may form without the aid of bruising in the manipulation of repeated examinations, but the second must be forced by bad management. The latter abscess, I have reason to believe, is the former abscess driven, by repeated manipulations, to burrow downwards instead of opening into the cocum.

    Fecal abscess, arising from ulceration of the colon, may be mistaken for appendicitis. There is a localized swelling, immovable in breathing or when pressed upon, and having a tympanitic sound on percussion over it with dull sound on pressure and heavy stroke.

    The symptoms of appendicitis are: Pain in the front, lower, right side of the abdomen. It is paroxysmal and caused in the main by peristalsis--the regular action characteristic of the sewer function of the bowels, which is for the purpose of forcing the contents of the intestines onward to the outlet, and which ordinarily is carried on without pain; but, in bowel obstructions of any kind, the onward flow of the bowel contents is cut off resulting in great pain where there is much irritability, for irritation of any kind always increases this expulsive movement. Food, taken in health, stimulates this contraction and if taken when there is inflammation--enteritis, colitis or inflammation of any part--the contraction is increased and necessarily painful. Think of the pain that the subject of diarrhea has, then imagine what that pain must be if there should be obstruction so that the fecal matter could not pass. That is as near as I can describe what the pain of appendicitis is. Anything that will stimulate these contractions will throw the patient into great distress. Food or drugs will cause pain, and water, the first few days of the illness, will do the same.

    In inflammation of the cecum, where the inflammatory process remains local and there is no obstruction more than constipation will make, the patient will be troubled with occasional attacks of pain which will pass as colic; or there may be a diarrhea, lasting for a day, every few weeks or months with constipation between the attacks. These cases may lead in time to ulceration, then to fecal abscesses and they are often diagnosed chronic appendicitis.

    When the inflammation is confined to that portion of the cecum that gives attachment to the appendix there may be no pain, or the pain may not be intense, and because of this lack of intensity, the patient tolerates abuse in the line of drugging and feeding until an abscess forms, the walls of which surround the appendix which is inflamed and often gangrenous. About this time, on account of the gradual increase in swelling, the pressure brings obstruction, partial or complete, causing the symptoms to become suddenly very dangerous; then if vigorous examinations are made to determine the exact status of the disease, don't be surprised if rupture of the pus sac takes place! This then demands an immediate operation which if performed will show a gangrenous appendix that had ruptured! This is quite common and is looked upon as proof positive that an operation was justified; in fact, the proper and only thing to be done, and it should have been done earlier!

    This is the opinion of the majority of the profession. It really appears that surgeons are innocent of the part they play in rupturing unsuspected abscesses and otherwise complicating this disease by much rough handling.

    The paroxysmal pain which is characteristic of the early stages of appendicitis may be accompanied by fever, sometimes low and sometimes high, nausea, vomiting and diarrhea. The vomiting may be severe and there may only be nausea. If there is much vomiting there will usually not be much diarrhea for the excessive vomiting is an indication that there is obstruction. In other cases there is both nausea and diarrhea; then the obstruction is either not established, for the trouble is as yet a local inflammation of the mucous membrane, or the diarrhea is from the bowels below the cut-off.

    It is safe to prognose obstruction when the vomiting is severe;; but if the nausea continues longer than three days,, it must be due to eating or to drugs, to taking too much water while there is nausea, or there is more obstruction than can be accounted for by such diseases as suppurative inflammation of the cecum or appendix.

    It will be well to remember that diseases of the cecum or appendix or both never cause complete obstruction, except in exceedingly rare cases where adhesive bands are formed, completing the cut-off. In this connection it will be well to also remember that in absolute obstruction the symptoms of nausea and vomiting, or retching, will continue, while those of appendicitis will stop in three days. In addition to the continued nausea of complete obstruction, the pulse grows weaker and more frequent and the patient shows great anxiety of expression, there is a sickness that can not be accounted for with a diagnosis of appendicitis or typhlitis, and the patient has the appearance of being desperately sick. The great pain at the beginning subsides, the temperature falls, the pulse grows rapid and weak, the skin becomes leaky, the mind becomes dull, drowsy and comatose, then a little wandering and death relieves the suffering in a short time.

    These symptoms are of collapse and they may come on in the course of a typhoid fever, or other diseases of the alimentary canal; they always mean a fatal toxemia either from obstruction or perforation, and occasionally the only forerunning symptom is sudden abdominal pain. Circumstances must guide in making a diagnosis. If, during a run of typhoid fever, there should be sudden abdominal pain followed with symptoms of collapse and nothing to account for it, it means perforation; an immediate operation may save the patient; nothing else will.

    A sudden pain in the abdomen of a woman during menstrual life, with positively no unusual menstrual symptoms and no trouble in the right ileo-cecal region, indicates perforation of the stomach or of the gall-bladder. If there have been a menstrual period or two gone over with a slight showing, and some uneasiness, perhaps nausea, perhaps a flow with pain somewhat simulating abortion, a sharp, severe abdominal pain followed with quickening of the pulse and an exceedingly anxious facial expression, ectopic pregnancy with rupture of the tube may be suspected. One must also keep in mind renal calculus in determining bowel diseases.

    Authors pretty generally unite in declaring that appendicitis is a dangerous disease. In his late book, "The Abdominal and Pelvic Brain," Dr. Byron Robinson of Chicago says, "Appendicitis is the most dangerous and treacherous of abdominal diseases--dangerous because it kills and treacherous because its capricious course can not be prognosed. . . . For years I have made it a rule to recommend appendectomy to patients having experienced two attacks. Fifty per cent of subjects who have had one attack experience no recurrence. "

    In Keating's Cyclopedia of the Diseases of Children, Dr. John B. Deaver of Philadelphia makes the following statements:

    "Appendicitis, whether acute or chronic, is essentially a surgical affection, and should be placed at once under the care of a skillful surgeon. The truth of this statement is becoming recognized in direct proportion to the general knowledge of the course and uncertainties of the disease, and at the present time only those who have but a limited idea of the course of the affection and have seen but a few cases, attempt to treat appendicitis without the advice of a surgeon."

    "Operation is the only procedure by which we can be certain of curing our patient. It is true that some cases do recover from an attack of appendicitis without an operation, but the percentage of those that recover from the disease is almost nil."

    "The main reason, however, why the appendix should be removed as soon as possible is that no one can state positively what course the disease is taking."

    "Although a strong advocate of the removal of the appendix in almost every case of inflammation of that organ, yet there are a few conditions under which I prefer to delay operation. When we find a patient with persistent vomiting, a leaky skin, a rapid, running pulse, a diffuse peritonitis and signs of collapse, I believe that operative interference is contraindicated. Under these conditions an operation would invariably be followed by loss of life. Ice to the abdomen, calomel pushed to free purgation, a small fly- blister below the ensiform cartilage, nutritious enemata, with stimulants in the form of whiskey or champagne, and hypodermics of strychnine, give a more hopeful prospect than would operation. When the peritonitis has subsided and the constitutional condition warrants, operation may be performed with a much better prognosis."

    The symptoms described by Dr. Deaver are those of collapse, following perforation, diffuse peritonitis to be followed soon by death, or of narcotism--morphine paralysis, soon to be described in extenso when we come to treatment.

    If the doctor ever had a patient presenting those symptoms and the patient lived after being subjected to the treatment he recommends, it is safe to say that he was dealing with an artificial collapse--a drug collapse--and he did not have perforation and diffuse peritonitis.

    This statement of the eminent Philadelphia surgeon adds another very weighty proof to my oft-repeated assertion that it matters not how eminent the medical man may be, he cannot tell the difference between drug and pathological symptoms. Of course this is a humiliating statement, and it is not expected that those very eminent medical men whom I charge with inability to differentiate between drug collapse and the collapse due to disease, will acknowledge that I am right, for, if their mental horizons extended far enough for them to admit it, it would not be necessary for me to say it.

    In no other way can the atrocious mistakes that doctors make in prognosis be accounted for. How many, many times doctors have declared that a given case must end in death, and they are so cocksure that they are right that they leave the patient to die; some sort of a fake, mountebank or fanatic comes in, the drug disease wears off and in a few days the patient is well. That is exactly the sort of a case Dr. Deaver describes. The faker gets busy with drugs that antidote the morphine poisoning, and occasionally a patient gets well in spite of all.

    In regard to surgery for this disease I shall quote from Ochsner:

    "Personally, I can only second the statement made by one of the most experienced men in this country in the surgical treatment of appendicitis, that there are thousands of surgeons who are otherwise competent, i. e., competent to perform the ordinary surgical and gynecological operations, whom he would not think of permitting to open his abdomen in case he personally suffered from an attack of appendicitis. This condition is true not because it is an especially difficult or dangerous operation, but because it requires an appreciation of the conditions upon which success and failure depend, and this appreciation can be obtained only by observing good methods.

    "In many of the ordinary surgical operations it is not necessary to follow out the details with any great degree of accuracy, because failure to do this will at most result in confining the patient to bed a little longer than usual or necessary, while in the appendicitis operation it is likely to result in the death of the patient.

    "This position, when taken in the discussion of appendicitis in medical societies, has frequently given rise to severe criticism because upon its face it looks as though appendicitis operations should be performed only by the few who happen to have acquired especial skill in this class of surgery, possibly at the expense of the lives of a number of patients.
    "This, however, is not the case. The operation is simple enough if one will but take the pains to learn it, and every town of five thousand inhabitants should have at least one man perfectly competent to do such work. But if there is no such man available then I would say most emphatically that the patient's chances of recovery are many times greater with proper non-surgical treatment than with an operation. Of course, patients have occasionally recovered, by accident, in the hands of most incompetent surgeons, but the death rate after appendicitis operations in the hands of incompetent surgeons is absolutely frightful.
    "My experience and personal observation have taught me that physicians and surgeons, as a rule, are absolutely conscientious, and that when they perform this operation, notwithstanding the fact that they themselves know they are incompetent (and they alone must necessarily be their own judges as to their competency), they do it because they have been taught that this is the only right treatment, and that the patient is entitled to an effort on the part of the physician or surgeon to save the life which is in danger. I believe that this is extremely bad teaching, and that many hundreds of lives have been sacrificed unnecessarily on account of this. I say this because I am confident that with proper non-operative treatment almost all of the cases which are diagnosed reasonably early may be carried through any acute attack, no matter what its character may be.
    "I would then say, primarily, that no case of appendicitis should be operated upon unless a competent surgeon is available. This, of course, does not apply to cases in which a circumscribed abscess has formed which anyone can open with safety provided he has sufficiently good judgment not to do anything further."


    Here I must differ. If the case has not been complicated by overmuch handling, digging, punching, thumping and otherwise manipulating in the name of bimanual diagnosis, no one has any right to put a knife into the pus sac for it matters not how well it is done the drainage is bad and is in opposition to the natural outlet through the bowels. Of course if the unfortunate patient has fallen into the hands of some one who believes it the prerogative of a physician to manipulate in season and out of season, and who has converted a typhlitic abscess into a perityphlitic one, or forced the pus to burrow towards the groin, then a free opening with a let- alone after treatment, except thorough drainage, may be followed in time by restoration to health; however, if the patient fully recovers it will be more from luck than from the usual management. 

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