DISCUSSION OF PAPER BY DR. NICOLSON.

Dr. Stewart: No man knows what conditions exist in the abdomen until he gets into it. I want to emphasize this. I remember one day one of my teachers, Dr. Lusk, tried to make fun of me about a case which I had examined and said there was a prolapsed kidney. He said that the woman had a retroflexed uterus, but I told him I would stick to my diagnosis, and when we got into the abdomen it turned out that I was correct. He turned to the class and said that he wanted to emphasize the fact that you can not tell what the condition is until you get into the abdomen. The best man can not tell.

The doctors don't treat the surgeons right about these operative cases. They will try to parley with us until the case is beyond our power to relieve, and then they will call upon us to operate, and of course the mortality runs high. It is our misfortune that men of moral courage stand between us. I think the doctor will endorse what I say, that three-fourths of the cases operated upon are in extremis, and we have to make the operation in the last stages of the worst cases, and then do the best we can. If the people die it is because they have not come to us soon enough. We do the best that we can under the circum

stances.

Dr. Little: I have enjoyed this paper very much. The emphasis Dr. Nicolson has laid upon making an early diagnosis, with the thought of converting it from a medical to a surgical case, is one that I heartily endorse, but the question of how to get the patient to the point of operation at this time is one that I would like to have the physicians. tell me. I have seen some cases of appendicitis in the last few months, and only one of these has been operated upon. One case I was called to see after the man had an attack in his store, and operation was advised, but the family ob jected. That man now has a second attack, and I am no

longer his physician because I advised operation. The question is to educate the people to the point where they will submit to operation at the proper time.

Dr. Noble: As I understand this paper, it is a plea for more careful diagnosis of troubles in the abdomen. It is a very broad subject, and recently a book has been written upon it. In diagnosing diseases of the abdomen mang things are to be considered. There are, above all, three points which should not be neglected. The first is anatomy, and no man can make a diagnosis unless he is a good anatomist. The next is the history of the case and the history of the disease. The third is experience, and 1 mean by that observation, and that is the most important of all.

Now, it is not necessary to try to lay down any plan for diagnosis, because the subject is too wide a thing for discussion at a meeting of this kind. I shall confine my remarks to one point only, because that point refers to the matter the doctor mentioned, catarrhal colitis.

There are women who have chronic conditions for months and years, and it is in these cases that confusion is apt to occcur. It is so commonly the case that men whose ambition runs in the line of appendicitis are so apt to attribute colicky diseases to that organ. Yet it is a very easy matter to differentiate between the two, and if you will take the trouble to follow up the history of the chronic colitis and palpate the colon, you can frequently distinguish it from other diseases, from the fact that it will usually roll up into a sort of cord or rope, which will distinguished it in almost all cases from appendicitis. You can trace it to the cecum, where you should find the appendix, and then you can differentiate it by the history, as you can not palpate the appendix between the attacks. In those cases which have not fully recovered there is a certain amount of exudate which can still be palpated,

and others which have recovered can not be palpated, and you are then obliged to rely upon your history. If you will follow the history of mucous colitis and the history of appendicitis you can make the distinction between the two. Numerous cases have been diagnosed as appendicitis when the organ was all right, and the history showed that it was a case of mucous colitis. In those cases they say that they just got them in time, when if the man was left alone the next day he would probably have been out plowing.

Dr. Clarke: The remarks by Nicolson are of great value, and well to be remembered by the general practitioner as well as the surgeon. I think it well for us whenever we find a pain in the abdomen which does not yield to treatment to consider the possibility of appendicitis and look for the proper symptoms to make a diagnosis, and after making the diagnosis to consider the probability of operation. It is also well to bear in mind that many cases recover. Just exactly the place to call in the surgeon I wish I knew, because I feel that every case is a great responsibility to me. I do promise one thing, that I don't intend to let a surgeon come in and operate on my moribund patients, because this brings surgery into disrepute, and my patients are not ready to consent to operation after this. I am sorry that my friend Dr. Stewart operates so frequently on these moribund cases. I do not believe in operation on these cases as a last chance. This is one reason why the general practitioner is so often turned down, when he suggests an operation upon these cases. People remember the cases that die, but forget the ones that recover. I do not see how the practitioners in Georgia can wait so long before calling in the surgeon. I do think it wise for use to bear in mind the points considered by the essayist.

Dr. Kime: This is a very important subject. Make

your investigations as extensive as possible. A doctor can not be too careful in his diagnosis. There are other organs in the body that may become diseased. It has been mentioned that mucous colitis is operated upon for appendicitis without relieving the condition. I saw a case that was operated upon for appendicitis, but did not get relief, and then it was diagnosed as mucous colitis. We find trouble caused by a movable kidney, or an inflamed rectum, and so we see that there is something else in the abdomen.

Dr. Nicolson (in closing): The discussion has gone entirely out of range of what I intended. I did not intend to discuss appendicitis. I would like to talk about it, but did not come for that purpose. I will speak of a few points bearing upon what I did say. My paper was simly a plea for a more careful examination of people's abdemens. I did not attempt to consider complete abdominal diagnosis. The point is, that when called to a patient suffering with acute abdominal trouble the physicians should satisfy themselves as to the cause of the trouble before they leave rather than to treat the case symptomatically. I agree with Dr. Stewart that no man knows what he will find in the abdomen before he goes in there. Every man who operates will find sometimes that he is confronted with a condition the opposite of what he expected, yet in some cases he can get a fair idea of what he is going to ind. Of course, every man should know something about the anatomy. When there is inflammation in the region of the appendix the burden is upon the appendix to prove not guilty. I have never removed an appendix that was not involved.

I did not expect to talk on when to operate, or when it becomes a surgical case, but I do think that when the practitioner has a case of acute inflammation in the abdomen that association with a surgeon will help him and save him

some sad moments later on. It does not mean that an operation is necessary because a surgeon is called.

I do not believe that appendicitis will get well. In the question of abdominal diagnosis, I did not expect to bring this up. All that I desired to do was to call attention to the fact that if a patient has a violent abdominal pain that he is often in a serious condition when we least expect it.

The patient who has violent abdominal pain should be subjected to a careful physical examination to make a diagnosis. Do not go on, and if anything turns up charge it up to misfortune. I was called to see a poor woman who was said to be suffering with intestinal obstruction, but a careful examination showed that she had a hernia and she was operated upon and got well.