appendicitis." One writer asserts that pain in the region of McBurney's point is a constant and very important symptom of this disease, while another will tell you that tenderness in this region is a more constant and valuable symptom than pain. One well known surgeon who annually operates on hundreds of cases, advocates one form of drainage, while another who also operates on a large number every year, advises and uses another form, and even goes so far as to condemn that used by the first mentioned; and so we may continue our investigations and study of the products of the numerous writers on this subject, only to encounter a continued repetition of such apparently and in many instances really contradictory statements.

It is self-evident and goes almost without saying, that the inexperienced surgeon, whatever may be his mental capacity, and though he may be ever so earnest, persistent, and conscientious in his determination to imbibe sufficient knowledge of the subject to enable him to always act promptly and without hesitation, will be doomed to disappointment; and will find himself in very much of a quandary when brought face to face with a case of this disease, as to what course is the safest to pursue in order to best conserve the interest of his patient.

By reason of the fact that there exists this great divergence of opinion and contradictory statements in the writings on this subject, there are those who claim that the subject has been worn thread-bare, and the profession has become worried from reading so much from the numerous writers or being forced to listen to such prolonged discussions as are now being carried on regarding this disease. In my opinion, such a view of the situation is a grave error, and if accepted as true, would prove undesirable, unsatisfactory and very detrimental to the well-being and best interests of both profession and patient.

The complications and treacherous nature of this disease have demanded and received of those treating it, the deepest thought and closest study, yet it is frankly admitted that mistakes often occur on the part of those most skilled in the treatment of this

disease. A close reader of literature on the subject is led to believe errors in judgment, more especially as to when radical measures should be resorted to, are much more common than they should be; notwithstanding the fact that the erring one may be unusually skilled, careful and painstaking and probably also enjoy the invaluable privilege of superb clinical advantages whereby he has constantly before him patients in whom he is able to observe the disease in all its various forms and complications. If the most skilled too often make mistakes, what are we to expect from the young and inexperienced operator; one who has seen little and probably read less of the disease, and therefore does not fully realize the real gravity and the great responsibility devolving upon him when administering to a case.

It seems to me most clearly important that the question of diagnosis and the proper management of this disease should be constantly agitated and kept prominently and conspicuously before the profession by every legitimate means at our command.

In order to more clearly and forcibly illustrate the concensus of opinion among leading surgeons and physicians of today, I will quote briefly from a few of them.

Symes says "That death from appendicitis is due to the one thing, and that is, too late an operation. In every case of fatal appendicitis, there has been a period when every patient could have been operated on successfully and safely." Symes also wishes to be understood as considering appendicitis a purely surgical disease. McBurney: "The number of practitioners who regard appendicitis as a medical disease, is rapidly diminishing."

Steel: "The mortality is less than 8 per cent during the first week and over 17 per cent during the second week, in operative cases."

Murphy: "By medical treatment, we have a mortality of 10 per cent, and we have 3 per cent by the knife."

Da Costa: "A large number of catarrhal cases are cured by medical treatment, but when the disease advances to pus formation,

surgical treatment is needed. If we err, let it be on the side of too early rather than too long delayed operation."

Deaver: "Excluding those in collapse, all cases of appendicitis should be operated on as soon as the diagnosis is made."

La Place. "In every case of fatal appendicitis, there was a time when, had the operation been performed, the patient would have survived."

Cartledge: "We should operate on every operable case as soon as the diagnosis is made."

Minter: "I have 5 per cent of recurrences after incision and drainage."

Porter has collected 177 cases treated by incision and drainage, with 13 per cent recurrence; though in his own series, he had only one recurrence in twenty-five cases.

Taylor and Morris advocate irrigating every abscess in suppurative appendicitis with hydrogen dioxide, followed by saline solution.

Paul Klen: "Catarrhal appendicitis should be treated medicinally and operation advised after recovery.'

وو

Barbat, in describing appendicitis, says that practically all patients who die after operation, we find at least forty-eight hours between onset of attack and time of operation; therefore, he says it is reasonable to assume that if the patient had been operated on inside of forty-eight hours, they would have been cured.

Grandin asserts that the less done after operating on appendiceal abscess and the establishing of drainage, the better for the patient.

Oschner thinks if patients suffering from appendicitis are seen during the first twelve hours, an immediate operation should be done, otherwise they should be left absolutely quiet; all cathartics and food by stomach are withheld; all nourishment being given by rectum. Stomach lavage is also advised when indicated.

Dawbarn believes the same discussions now taking place regarding appendicitis will occur twenty-five years hence.

The opinions here quoted are from among the most able men in

the profession, being the product of an experience resulting from the observation, study, operation and treatment of many thousands of cases. Almost without exception, it is agreed that appendicitis belongs more properly to the domain of surgery than medicine: a majority of writers also agree, and some of them assert most emphatically, that operative treatment applied to all cases, yields better results than medical treatment.

When to operate and when not to operate, we find a great diversity of opinion; an existing condition which bears out the contention made before, that although the profession possesses a large amount of knowledge concerning appendicitis, it has not advanced sufficiently to enable us to lay down any fixed rule as to when and when not to operate. The present status of the treatment of this disease is certainly not all that is to be desired, yet, such as it is, today some able men are inclined to believe it will be twenty-five years later; at least so far as it has to do with a classic symptomatology and a uniform method of treatment, are concerned.

The cases which I will report, in my opinion very aptly and forcibly illustrate the difficulties to be overcome; the great responsibility of the surgeon or physician in his efforts to draw conclusions and arrive at a decision as to what to do and when, if at all, it should be done. So far as they go, they also illustrate the fact that a certain group of symptoms of equal intensity, observed in two or more cases of the disease, does not by any means indicate that all are afflicted with the same form of the disease.

CASE 1. B. T., male, age 26 years, brunette, slender build, weight about 145 pounds. Patient had been residing in and about Beaumont all his life, and with the exception of a few malarial attacks, had always enjoyed good health. His first serious illness dates from the time he was encamped at Montauk Point, while serving in the capacity of volunteer soldier, during the SpanishAmerican war. Here he suffered from indigestion and a number of attacks of diarrhea. Returning home after a cessation of hostilities, his health improved and remained good until the first part of October, 1902. At this time he suffered a short and comparatively

mild attack of fever and diarrhea, the fever being pronounced by his physicians as malarial. During this illness he suffered for several days from obstinate vomiting, being unable for four or five days to retain anything except a very small amount of liquid, and often not that. His physician at this time, Dr. F. S. Martin, of Beaumont, tells me he would at times swallow several consecutive glasses of water, each one being ejected before taking another. This partook more of the nature of regurgitation than vomiting, coming away without effort on the part of the patient, yet he was apparently unable to prevent this action of the stomach. In about three weeks from the beginning of illness he recovered sufficiently to be able to leave Beaumont, going out in the country some twenty miles away, where he improved some but did not become strong; and in a few weeks was again taken down with fever, which was at first thought to be malarial, but later proved to be typhoid. About three weeks after the beginning of this attack, patient began to suffer pain in the region of the appendix. This pain continued to be more severe, and two weeks later the case was diagnosed as appendicitis. As the patient objected to operation and his condition not appearing alarming, his physician did not insist, deciding to await developments, so long as the patient's condition did not indicate an imperative necessity for operation. His condition remained practically stationary for about two weeks after the first manifestation of symptoms of appendicitis, and then began to slowly improve. In the interval a mass the size of a small fist appeared in the region of the appendix. This mass at first was exceedingly tender and somewhat painful. As the patient's general condition improved, this tenderness and pain became less marked, the size of the mass not appreciably increasing or decreasing. The patient's condition had now ceased to improve; although his fever left him, he was unable to sit or stand on account of weakness and pain, which such movement would provoke in the region of the mass. The above is an imperfect history of the case up to the time I first saw him, on December 29, 1902, at which time he had been referred to me for operation by his physicians, Drs. E. D. Pope and J. W. Swonger, respectively of Kountze and Hook's Switch, Texas.