I believe every individual who has recovered from a decided attack of appendicitis should be advised to have an interval operation done. Every case of relapsing appendicitis should be operated on during the quiescent stage if possible. If, after forty-eight hours, under appropriate medical treatment, there is a distinct improvement in all the symptoms, I should be in favor of continuing the medical treatment under careful surgical supervision. If, however, the symptoms are progressive in the face of medical treatment, immediate operation is indicated. A sharp recurrence of the acute symptoms during the progress of a medical case pursuing an apparently favorable course also indicates operative interference. According to my observations children under twelve years of age bear appendicitis poorly, and should be operated on at once. I have seen ten cases of appendicitis in children; four of these I saw only when they were practically moribund from general peritonitis; one died on the third day, one on the fifth, one on the eighth, and one on the tenth day from the onset of the disease. All were treated medically throughout. In all except the first, I advised operation as the only hope, but surgical intervention was declined. I have removed the appendices of three children; all recovered. I assisted one of my friends in Atlanta in two operations on children; one died, the other recovered-one case seen in consultation, where I advised operation, recovered from the attack. The five operations on children revealed conditions from which it would have been absolutely impossible to have recovered without surgical interference. Appendicitis is a surgical disease, and every case should be considered from a strictly surgical standpoint.. Dr. Joseph Price, of Philadelphia (closing the discussion): You doubtless remember the story of the Boston man who, fearing that he might faint on the street and be carried into a hospital and operated on for appendicitis, had printed on his underclothing, "My appendix has been removed." Considering this subject purely from the standpoint of mortality throughout the country, I wish to say that the mortality is high, and it is foolish for physicians to talk otherwise. The Manager of the Windsor Hotel, New York, died of appendicitis—a delayed operation. The Mexican Minister, at Washington, died of appendicitis. A very dear friend of mine (Dr. Nelson, of Danville, Virginia,) died a very few days ago of appendicitis. He had had several attacks, and I begged him repeatedly to let me remove his offending member, and he would not consent to it. My friend, Dr. McRae, who has just preceded me, has done good surgery. He is quite capable of doing it. But he should bear in mind one thing, that to every patient who sends for him he should give the one lingering chance for his or her life. We must bear with the bad statistics that are the result of late operations. I hold that we should give every patient a chance for their lives if they still breathe. It matters not how far gone they may be, we should not let them fall by the wayside, as was the case with one or two unfortunate soldiers at El Caney, who received wounds in the abdomen and were not operated upon, the surgeon giving the excuse that the food was improper. I am surprised that the American army should have a single surgeon in its ranks who would refuse to open a soldier's abdomen and tie a mesenteric vessel which was cut in two, thus permitting the patient to bleed to death. I took the liberty to refer to this matter of surgical timidity or stupidity in a talk with the Secretary of War. A word or two with reference to serum-therapy. We have long been in need of a serum-therapy that will cure all of these cases, but as yet we have been disappointed along all lines. The hospitals for children report not very encouraging results either from its use in diphtheria or scarlet fever, and, I am quite sure, in pneumonia and other troubles the results have been far more favorable. Again, in puerperal infections the results have been anything else. but satisfactory. Patients, from whom I have removed malignant disease, feeling that it would perhaps be a good thing to make their recoveries sure, sought serum-therapy after very successful dissection of the axilla, and laying everything bare, leaving the vessels, and with fatal result. If any of you were to write to one hundred or a thousand boarding-schools or colleges as to how many of their pupils. have died in September, October, etc., you would find thenumber to be unusually large, because we know that in every boarding-school and every college we have cases of recurrent appendicitis without a cure during the summer having been effected, and they die. The mortality from appendicitis in the University of Pennsylvania among the students has been one and two per cent. for many years. While the Lafayette football team was playing in Philadelphia, Dr. Deaver removed the appendix from the Captain. The Captain of the University Baseball Club, while playing baseball was seized with appendicitis and died in the University of Pennsylvania Hospital. Athletes of national reputation have died in large numbers from this disease in the educational centers, in their own colleges. I have been frequently called to Princeton College and to Bryn Mawr and other towns to see either a young girl or a young man who had been treated for five or more attacks of appendicitis, have operated, removed the appendix, have had the specimen in a bottle, when such cases have been. reported by physicians at county, State, and national societies, as cures. That is the point I wish to make, and no one dares to report a recovery scarcely, for while he is talking some surgeon may have the specimen in a bottle, removed in consequence of a later attack. I remember one case of appendicitis in which the patient traveled all over the world. It was an historic case. For instance, the man had appendicitis maybe in Holland; he went to France and later to Germany, having attacks of appendicitis in all of these places, and then returned to London, where he consulted Treves, and said, "Doctor, my business interests are very large; I have had three attacks of appendicitis away from home, and I dread the possibility of a subsequent attack, and my appendix ought to be removed." These statements influenced Mr. Treves to remove the man's appendix in the interval, because it was not only a demand but a command on the part of the sufferer. Pause and think of this. I have a perfect horror of needless surgery. Some time ago I was guilty of making the statement that if I could remove the appendix when I tied the cord with the same safety, I should do so in all cases. This statement traveled over the city of Philadelphia like wildfire, and a very rich woman drove up to my office with coachman and footman in full livery and presented her card. She said to me, "I understand you are recommending the removal of the appendix when the cord is tied in little babies." I was somewhat startled by this statement, and after collecting myself, I looked at her and said, "My good madame, I have six dear little babies of my own, have tied the cord in all of them, but have not removed the appendix in any one of them." Alluding again to the mortality, at Pennsylvania University and Princeton Colleges it was large for years. Agnew and others were called there for appendicitis, and hesitated to operate, and the consequence was that in many instances the patients died. Now, a physician hardly dare go to Princeton College to see a case of appendicitis and urge non-operative interference. They only call men who come prepared to do their bidding. The mortality from appendicitis throughout the country is large among our doctors. Many of them have been operated upon, with a high mortality. It is surprising the number of cases that have been operated upon in Philadelphia. I allude now to physicians who have been operated upon. The class of doctors that resisted operative interference so long are now the most ultra men in these operations, both in Philadelphia and New York, and in all the educational centers. For a long while Ashhurst, Deaver, and those of the Ashhurst school were inflexible obstructionists on this point. Young Dr. Maury, of Memphis, while a resident physician in St. Agnes Hospital, saw Dr. Deaver turn down two cases. These two patients were treated by mercurial ointment, etc., but what followed? The patients left St. Agnes, went to other hospitals where the appendix was removed. Deaver soon recognized that there was but one treatment for this disease-operation. His friends died all around him. His position now is the best in the country, and he is doing the best work. One of the most distinguished and accomplished surgeons of the country sometimes says to his class: "Gentlemen, this is one of those cases in which there is no appendix." You all know that this is an error. None of you will ever fail to find one if you search for it. With reference to those cases in which we find a large quantity of pus, with a lurking, cheesy, disorganized, gangrenous mass at the bottom and multiple abscesses, do you recognize that you may have a general suppurative or infectious peritonitis to deal with, and do you make a general toilet and attempt to arrest infection and save the lives of your |