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FIG. 3. Showing same appendix more highly magnified. Lettering same as in figure 2.

DISCUSSION.

DR. H. W. CROUSE, Victoria: In appendicitis, the nicest surgical discrimination presents itself to a surgeon in deciding when and when not to operate. There is no analagous surgical condition which is its equal. We have this difficulty presenting itself with frequent pulse and rather high temperature, with marked pain, peritoneal pulse, nausea and the classical

signs of suppurative conditions; but, on operating, we discover instead a merely catarrhal inflamed appendix to exist. Last November, while in St. Louis, a discussion arose between Dr. Bernays and myself as to what were the inducive causes of death in catarrhal cases, where, post-mortem, no septic conditions were found. Dr. Bernays stated to me that he had often found, of late, that the lymphatic glands, a group of which Dr. Keiller informs me lies behind the appendix and act as an appendicular drain, also another group which lies between the angle made by the conjunction of the ilium and colon, are frequently found to be suppurative. Analagous to the suppuration that takes place in the inguinal glands in gonorrheal or in chancroid cases, Dr. Bernays stated that he had seen several cases, post-mortem, where these glands, on being carefully examined, were found to be slightly congested externally, and when incised were replete with pus. This conclusively proves the reason why we, at times, have the misfortune to have a catarrhal appendicular case terminate fatally, and should we surgeons but delve beneath the appendicular area and investigate the glands, removing them if they are found to be suppurative, we should, in all probability, at many times, save cases which, at present, we lose. Dr. Bernays showed me a little plan that he had for removing pus from deep pockets, which Howard Kelly has added to his revised edition of "Operative Gynecology," namely, the use of a glass tube, a simple pipette, by means of which he was able to withdraw pus from deep cavities that would have been difficult to have been cleared in any other way.

DR. W. B. COLLINS, Lovelady: I would like to make this point in regard to these cases. Although we are not surrounded by the best environments, and we do not have hospitals, trained nurses, expert anesthetists, etc., at our disposal, their absence alone should not cause us to decline to operate. The great desiderata are these: Can we do the operation aseptically and antiseptically? Upon our ability to do clean operations, our success depends. I think we can prepare our water just as sterile, make our solutions just as accurate, and clean the field of operation just as well in the country as in town. These are the main questions for us to decide. I speak of the disease strictly in a surgical sense. First decide whether or not an operation is imperative to save life, and then proceed without hesitation to do it. We should not throw up our hands and surrender because we have not the best facilities for operating. A little heroism among the profession will result in great good.

DR. T. P. WEAVER, De Leon: I just want to say that I was glad to hear what Dr. Crouse said with reference to our disability in caring for our patients; that we are often called to those cases that are removed from hospital advantages and the benefit of a trained nurse and a great many other

things. In our practice as medical men we are called to see a man may be a number of miles from any trained nurse or hospital, say in the country; it becomes our duty just as often perhaps to see a case of appendicitis, and a case which demands immediate operation, as in the city physician's practice, who has a trained nurse and a hospital at his back. Now, I want to say that I believe that it is as much our duty, even if we are fifty miles from the railway, hospital or trained nurse, and that if proper aseptic rules be carried out, and if he is satisfied that his diagnosis is correct, I say that it is the duty to give that patient to the best of his knowledge the best treatment and select the course that will result in his recovery. Now, if he needs an operation, we can prepare for one in the country; we know how to asepticise our hands and how to have the patient prepared, also how to sterilize our gauze, ligatures and instruments and see that everything about the patient and room in which we operate is prepared in a few hours, and we can do a comparatively aseptic operation and save the life of our patient. It is not right to lay our hands down and say, if this patient was in a hospital in San Antonio, Austin or Waco, his life could be saved; but do the best thing that we can for our patient, and with a pure atmosphere and no contamination from germs, we will get just as good results fifty miles in the country as though we were in the city; and if we work along this line, our success will compare favorably with almost any man in the city.

DR. J. H. REUSS, Cuero: In the paper of Dr. Decherd, referring to the anatomy of the appendix, did I understand him to say the muscular structures and the lymphatic substances were markedly increased at the base of the appendix, and the muscular structure less well defined as it approaches the apex? If this be the case, we can readily understand the entrance of any foreign substance or infection entering the appendix being cut off from a return drainage to the bowel on account of the increased constriction at its base, and this "damming up" in the caliber of the appendix in turn producing an increasing catarrhal inflammation.

DR. J. M. NICKS, Stone City: In regard to these operations. We are frequently called to a case and find it to be appendicitis, and will urge an operation. The country people as a general thing fear the knife. I have seen numbers of cases where at first conditions were not grave. I would hesitate in these conditions to do an operation. I would wait for a day or two, see the condition of my patient getting serious, and would say to the people that we had better have an operation. But they would hesitate, express their views and fears, and hold back with the hope of his getting better. Sometimes bad cases get better without an operation; but if the case is in articulo mortis we then are at the point when an operation would bring disrepute upon ourselves.

Sometimes we have to say: "I take my hands off this case if you do not give me permission to operate." We have our reputation at stake in these matters, and frequently some member of the family, or somebody else, puts his opinion against the doctor's. We have the case, and he needs an operation to get well. We get the consent of part of the family to operate. We do the operation and he dies. We have just killed ourselves in that community. The best thing to do in a case of catarrhal or other severe form of appendicitis is to give the patient for a sufficient length of time the benefit of medicinal treatment, and if we find that there is likely to be a fatal termination, we must then and there decide what to do. If they say no, we should refuse to treat the case longer.

DR. F. D. GARRETT, Gainesville: I think there is a favorable time in these cases to operate, and an unfavorable time. I believe that in every case of appendicitis it is best to inform the patient that an operation might become necessary. I believe there are some cases of appendicitis, particularly of the catarrhal form, in which it is better not to operate, better not to advise operation. Cases which are very mild, in which the patient has a little pain, no temperature or a very little temperature, may be safely postponed. If he has a recurrence of the same trouble, it is better to advise operation; but if the attack is still mild, wait until he recovers from it, then perform the operation during the interval of time which intervenes between that and the next attack. There is another class of cases of a virulent type, with rapid pulse, high fever and great pain, a malignant form of appendicitis. In this class it is our duty to do an immediate operation and the sooner it is done the better for the patient and all concerned, and I would advise immediate operation. If they did not consent to the operation within the first thirty-six hours, the physician ought not to risk the life of his patient and his reputation by operating. Of course, there will be exceptions to this, but as a rule, where those cases are postponed over thirty-six hours, on opening up that patient's abdomen, you break up adhesions which might have formed if you had postponed the operation, and you deprive the patient of nature's protection, which, at this late hour, is his best friend. By way of illustration, I can cite from my own practice two cases which I recall now. One of a mild type, of a catarrhal form, in a young lady, a school teacher, about twenty years old, who had attacks of appendicitis following each other at intervals of a month at first, then two months intervened, having in all five distinct attacks. They were very mild, except the last one that she had, from which she suffered a great deal. On account of these attacks coming just about the menstrual period, there was some little doubt about the diagnosis, but I felt very sure that it was appendicitis. When she had the fifth attack she was out of the city and when she came back home I advised her to be operated on, and she submit

ted, and got along all right. The second case was a little boy about five years old. I was called to see him about one o'clock at night and found him suffering intensely, temperature 105, pain all over abdomen. About three or four hours later when I called the pain was localized at McBurney's point. I advised operation next day, and the family consented, just twelve hours from the onset. We operated on the boy and found and removed a gangrenous appendix. The boy recovered.

I merely wanted to try and bring out the point that there was a favorable time in these cases to do an operation and again an unfavorable time.

DR. WM. KEILLER, Galveston: Within the last twelve months Dr. Ochsner, of Chicago, has written a hand-book on appendicitis, which is a landmark in the treatment of appendicitis and will answer the question: What to do when operation is impossible. I think upon the whole Dr. Ochsner advises that if you can not operate in the first twenty-four hours you should follow the treatment that he outlines. It is impossible to epitomize what he says, but as nearly as possible he gives absolute rest, washes out the stomach, gives absolutely nothing at all-not even water-by the mouth, and feeds entirely by the rectum until the symptoms have subsided, and then he insists upon operation; and if he can not get it, he washes his hands of the case. I advise all who have not seen the book to get it without delay and read it.

DR. H. A. BARR, Beaumont: It is interesting to me to note that in the discussion of this disease by members of this Association there exists practically the same difference of opinion as to what to do and when to do it, as is found among the greatest operators of our country. This same question has been asked by the leading physicians and surgeons in the land. Now, we have no uniformity of method as to what and when to do it. We have cases of appendicitis attended by mild symptoms, and the patients go on and get well; then, again, there are cases, for instance in my own town today, among men that I have seen that have suffered from appendicitis and are apparently well and able to discharge their duties as business men; there are many others, also, that are in the grave who had mild symptoms, just about the same as the others apparently. Many were advised to be operated on, but refused, and recovered without it. I have told their friends that they have to be careful. Two or more cases may have exactly the same symptoms, and one may die and the others may not.

In regard to these cases and the anatomy of the appendix, I think it is generally recognized that infection takes place through the lymphatics. The appendix is generously supplied with lymphatics, hence peritonitis takes place from a very small focus inside the appendix.

You may be called twelve hours after the inception of the attack, and

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