As stated earlier, the blood picture is a matter of great interest and importance. I have had a leucocytic and differential count made on all the cases. Usually one finds an increase in the leucocytes and also polymorphonuclear elements. However, if one were to rely on the leucocyte count alone, he would often be deceived, for several of our cases showed a low normal leucocyte count with an increase in the polys and yet the appendix was found to be very acutely inflamed or even gangrenous. On the other hand, the leucocytes may be high and the polys low and the appendix badly infected. In no case was there a low leucocytosis with normal polys and this is important, for if such a combination was found, acute appendicitis could be ruled out. It has been my experience that where the leucocyte count was low with a great increase in the polys, say 93% to 96%, the convalescence was slow and protracted; that a high leucocyte count with a moderate increase in the polys meant a speedy and uninterrupted recovery; while a high poly with a high leucocyte count usually meant drainage.

The complications noted after operation were as follows: three cases of pneumonia, two fecal fistulas, two residual abscesses, and four cases of ileus.

Lung affections occurred only in the cases where sepsis was already present. There is no question but that the routine preliminary use of atropine and the administration of the anaesthetic by skilled anaesthetists accounts for the fewer lung complications following operations of to-day, as contrasted with the large number of these troublesome affections that occurred before the popularity of atropine and when the administration of ether was entrusted to the family physician or the youngest hospital interne.

Residual abscess is not at all uncommon and should be suspected when a post-operative fall of pulse and temperature is followed by local tenderness and swelling accompanied by a rise in the temperature and pulse rate. In our two cases under ethyl chloride anaesthesia, a digital exploration along the tract of the tube evacuated pus.

The two cases of fecal fistula developed in cases of gangrenous appendices where the gangrenous process involved the cecum as well. Like the majority of these cases, both healed spontaneously; one in four, the other in six weeks.

Ileus, when encountered, should be treated heroically from the very beginning. It has been our practice to wash the stomach of all patients vomiting twelve hours after operation. One will be surprised with the good results obtained after this early lavage, but if vomiting recurs the procedure should be repeated. Pituitary is of unquestioned value in promoting peristalsis, and should be injected into the muscle in doses of 1⁄2 c. c. every hour for four doses. Enemata containing turpentine when combined with the above in all our cases has been sufficient to overcome post-operative ileus. Should the above fail to bring about relief, one should not hesitate in reopening the abdomen and seeking the cause of trouble.

In recording the number of days spent in the hospital by this group of patients, I have found it best to classify them into two divisions; those requiring drainage, and the non-drainage or clean cases. Out of twenty-nine cases drained, two died, the remaining twenty-seven passed 630 days in the hospital, or an average of twenty-four days each; while the twenty-one cases spent 274 days in the hospital or an average of a little better than thirteen days each.

What a marked saving to the patient who has not required drainage, not only financially, but socially and physically as well; and what a decided and important aid to the surgeon also, who can say to his medical brother, "I can send your patient home cured in thirteen days if you will only send him to me when his appendicitis is beginning."

In conclusion, let me state I cannot recall a single fatality in the operation of acute appendicitis performed during the first twelve hours following the onset. When one compares this record with the increasing mortality following every hour's delay after the first day of illness, I positively maintain that no criticism is too severe for that group of men who will say, "Yes, it looks like a cold in the intestines, but there is always a chance

of it being appendicitis. I will treat you medically for a few days and if you do not improve, it is then time enough to call in a surgeon."

DISCUSSION.

DR. DANIEL SULLIVAN (New London): Gentlemen, Dr. Shea's suggestion that we reconsider the question of appendicitis, to me seems timely and very important. I do not believe that we should reconsider it on the ground that we know less about appendicitis than we did fifteen years ago, but we might reconsider it on the ground that we know more about the other conditions that simulate appendicitis in the early stages. It is mighty disappointing to send a child to the hospital for operation with a diagnosis of appendicitis, only to find a few days later that the case was really suffering, the pain was really due, to a diaphragmatic pleurisy that we know so often ushers in a pneumonia. It is depressing to take out an appendix because there has been pain in the region of the appendix and find that your patient still goes on with a fever and after a few days you learn that you did not have appendicitis but had a case of typhoid fever. And it hurts when you take out a perfectly normal appendix and find that the pain recurs, and recurs again, and sometime within the next year the patient walks into your office and deposits a renal calculus on your table and says "Ever since this was passed I have been feeling better." I feel that these are conditions that keep the general practitioner from jumping at conclusions and hurrying the patient to the operating table. The most common mistake that I find is the waiting for some one symptom or one condition upon which to reach a conclusion. So many times a man will say "I don't believe that this is appendicitis, or if it is appendicitis it does not amount to anything because there is no fever or very slight fever." It is a well known fact that an appendix can go to the point of perforation and it can go on to gangrene with very little or no fever.

Another condition; a man will say "There is no tumor mass; I am waiting for the tumor mass to form. I don't believe it is appendicitis because there is no tumor here." When we get the tumor the damage is done. In ninety-nine cases in one hundred I think you will all agree the appendix has already ruptured. If it hasn't ruptured it is so close to it that the peritoneal coat is barely hanging and it takes a mighty expert man, and an appendix must be in a mighty convenient position, in order to remove it without rupturing it. I believe the most common failure of all is depending on abdominal rigidity. Now, you get abdominal rigidity in the majority of cases; in so many cases where the appendix is situated in the pelvis you can get perforation, you can get an abscess, and you can have a high grade of pelvic peritonitis and you can thump and punch

the abdominal wall quite freely and elicit no pain and cause no spasm of the abdominal muscles. I believe if more men would make it a practice to examine per rectum, get the finger accustomed to the normal condition per rectum, that they would frequently find the mass that spells appendicitis.

In looking over the reports of several of the hospitals of the state I found that their mortality from appendicitis was very low, very low, in spite of the fact that most of the cases that come to them come in the pus stage. I don't believe we should consider the question of mortality entirely, although we should strive to get down to the zero mark. We have the patient's post-operative health and comfort to consider. Then there is a question of economics that comes in. If, as Dr. Shea says, we can get a case in the first twelve, or we might say in the first twentyfour, hours we know that in the majority of cases the appendix can be removed and the wound closed and the patient will be confined not over seven to ten or twelve days, and in another week the patient is ready to take up his regular occupation. But when we get pus, it means weeks and many times months of convalescing. The patient is not only put to a great deal of expense but it is a great loss to society in general.

The operation of appendectomy in itself is a simple operation in the majority of cases, but when we get pus it is a different proposition. The draining is very important, and as Dr. Joe Price says "He who drains well does surgery well,"-applies more I think in cases of appendicitis than in anything else.

DR. LAMPSON (Hartford): Mr. Chairman, I think that Dr. Shea's paper is at this time very fortunate because we have all felt in our hospital services that the men on the outside, the general practitioner, had come to the conclusion that the surgeon could save all cases of appendicitis no matter how bad they were. I think that it has been noticed that with each succeeding year during the last four or five years, we have had a greater proportion of pus cases, a greater proportion of general peritonitis cases, and cases that, therefore, had to be drained. I don't believe it is lack of ability of the diagnosis in these cases as much as it is confidence in the ability of the surgeon to cure them no matter how bad they may be. I think it is a mistaken reliance on a surgeon's ability because there are a certain proportion of cases that we cannot save. Then, on the other hand, there are some cases, some patients, who are so oblivious to pain that they bear their abdominal pain without consulting anyone and they come to the surgeon or they come to the physician and, on the first call, the physician finds that that patient has a ruptured appendix possibly, or a general peritonitis, and he rushes the patient to the hospital. That has not been the physician's fault. That has been the patient's fault.

I remember very well one such case that I had a short time ago where a young man had appendicitis for three days. He was operated on within three and a half hours after he was first seen by his physician. So I don't think it should all be put up to the general practitioner; it is partly up to the patients themselves.

Of course there are, as we all know, some conditions which simulate appendicitis besides those that were mentioned by Dr. Sullivan. I mention this case simply as one of them.

I had an experience in my own family of the difficulty of diagnosing appendicitis. My small boy, six years old, was taken with an attack of acute abdominal pain. The only thing I could think of was appendicitis. I called in a fellow surgeon to see the boy and he said: “No, it can't be appendicitis with such a lax, flaccid abdomen and normal leucocyte count. The diagnosis was Potts' disease of the dorso lumbar vertebra and the pain was referred to the umbilicus from pressure on the posterior dorsal nerves.

As to drainage of abscesses, I can't quite agree with Dr. Shea. I think the sooner we get the drains out the better. I think drains are left in too long, because after three or four days a drain, whether it is a rubber tube or a cigarette drain, does very little good. If it is necessary to open up the tract again, why do it by some other means than by keeping a drainage tube in there too long.

In the cases of general peritonitis I think the methods have changed so that no one now ever flushes the abdomen or anything of that kind. The aspirator is of great assistance. It should be used with much care where we have general peritonitis. The less the tip is poked around in the cavity, the better. It should be used in the appendical region and in the pelvis and put in no other place.

If you want to find out if you have pus on the other side of the abdomen, the best thing to do is to make a counter incision but do it with clean instruments and a new pair of gloves, so that if you do not find it you have not contaminated that side of the abdominal cavity.

DR. E. H. ARNOLD (New Haven): I do not operate on appendix cases but hope I send them early enough to the general surgeon. Two things appeal to me in the paper of Dr. Shea's and Dr. Sullivan's discussion. The way Dr. Shea dealt with the old superstition that a piece of gauze will drain an abscess. Gauze will drain liquids by capillary action of its meshes. When these become filled by more or less solid matter such as flucculent pus its capillarity ceases and it will not even drain fluid. The advice to use rubber tubing is good for all kinds of drainage. Even the smaller sizes of this become plugged and the fenestrae of the larger ones become obstructed. Therefore, the rotating of the drain is a small but important item in the technique of draining. Dr. Sullivan draws attention