Ochsner, his skill in that direction is very con-
siderable. But when we come to these cases
of suppurative general peritonitis, I confess
that the views of the essayijyt give me a shock.
Digitized by LjOOQIC



374



APPENDICITIS— OCHSNER.



Jour. M. S. M. S.



The cases of that kind that have come under
my care have been ones in which the first
symptom expressed by the patient occurred
when an appendix that had evidently been dis-
eased a long time, perforated; that diseased
appendix had not produced any symptoms.
They had become enormously thickened and
ulcerative process had been going on, and
finally it perforated, and when the perforation
occurred the patient was taken violently ill
with severe pain, with hard, tense, rigid, ab-
dominal muscles, and an immediate diffusion
of the suppurative process throughout the peri-
toneal cavity. It is very difficult for me to
realize that it can be possible by any form of
treatment to confine that inflammation or to
secure adhesions when that form of inflamma-
tion has started and the only cases of that
kind that I have seen recover have been those
in which the operation was performed in the
first 36 hours after these violent symptoms
commenced. After 36 hours if I do not get an
opportunity to operate such cas«s, I shall be
most happy, hereafter, to follow the recom-
mendations of Dr. Ochsner and give his method
a trial, because I have never seen them get
well with or without an operation, unless I
operated within the first 36 hours.

I have been very much interested in this
paper of Dr. Ochsner's for another reason:
F*or several years I have received occasionally
from the laity this message: **Why, in such
a town they don't operate for appendicitis at
all; they treat it by the starvation method;"
and I am very glad to have this brilliant ex-
position to the Michigan State Medical So-
ciety of the real purposes of the starvation
treatment— a preparation for operation, not a
substitute for it.

S. C. Graves, Grand Rapids: I know that I
but voice the sentiment of all here present
when I say I am glad to have been present to-
night — glad that I have been here to listen to
such a magnificent paper — a paper so up to
date, if I may use that expression, so much in
touch with the modern idea. And yet many
t)f us knew the principles which this paper
contained before we listened to it. Those of
us who have had some experience in operating
for appendicitis, or in treating cases of ap-
pendicitis, have been acquainted for some time
past with Dr. Ochsner and his views. We
knew what he would say. In fact — and I say
it in all modesty — for years past my own ex-
perience has run along the same line. It did



so before I was aware there was such a man
on God's footstool as Dr. Ochsner. My senti-
ments were crystalizing in the same fashion —
not, perhaps, to the same degree, but along
the same line as those of my colleagues know
who have heard me talk.

There has been a spirited controversy for
years between two classes of operators' in ap-
pendicitis. . This discussion has never been
acrimonious; but it has been, as I say, spirited,
and it is going on even to the present day,
although, as Dr. Ochsner informed me this
afternoon, it is growing less and less, and
some of our opponents are coming our way.
Deaver, Richardson, Morris, Fowler, Murphy,
possibly our own Carstens here, have been in
the extreme class, operating quickly, early, in
time, and every time. That is the position
which I took myself early in my practice. I
regretted it quickly, and I soon stopped oper-
ating that way. I think Brother Carstens, too,
. is not quite so forcible in his recommendations
as he was some years ago in that particular.

Appendicitis is not as dangerous a disease as
people have thought it was. It has proven
dangerous, I know, but it has been made so
by mis-treatment or by over-treatment. If you
study the natural history of appendicitis, you
will find that it is not such a dangerous dis-
ease.

It will terminate naturally in one of four
ways: first, by resolution, seeming or real;
second, by the development of a local, circum-
scribed abscess; third, by a sub-acute or
chronic state of inflammation; fourth, by a
state of a general septic peritonitis. The mor-
tality rate in my experience has been just one
hundred per cent in this last group of cases.
Whether operated upon or not, they all die.

Now of these four terminations, the first
three are not particularly dangerous, though
of course any type of appendicitis carries with
it more or less danger. The fourth and last,
of course, is.

If we could eliminate the factor of septic
peritonitis from our cases, appendicitis would
be very slightly dangerous to human life. Dr.
Ochsner is securing this result by his plan;
he is eliminating, to a large extent, that terrific
enemy to human life — septic peritonitis. And
I do honor to him to'-night in making that ex-
pression; I believe it to be a fact.

Now as no chain is stronger than its weak-
est link, and as all chains have some weak
links in them, I think this paper of Dr. Ochs-
ner has some weak points. As Dr. Dodge said

Digitized by VjOOQIC



September, 1904.



APPENDICITIS- OCHSNER.



375



before me, it may seem presumptuous for a
man of limited experience to criticize one of
greater experience; but, after all, each of us
has his own opinion and we have a right to
that opinion if it is based upon reason. That
reason, however, may not be a very sound
one; but if we believe in it we have a right to
express an opinion based upon it. The point
has been raised that cases can be safely oper-
ated upon at any time prior to what I may
term extra-visceral involvement; that is, while
the micro-organism is still within the lumen
of the appendix. As both Drs. Dodge and
Ochsner have said, we all admit that if this can
be done all is quite well, but I maintain that
this is a point concerning which the man does
not live who can be sure of his ground — who
can be certain that he is operating prior to the
migration of microbes through the walls of the
appendix. He may do that, and of course as a
man grows in judgment and knowledge he can
become somewhat surer of his ground; but I
do not believe that action at such time has any
basis in certainty. In fact, I know it has not.
I am a little surprised that Dr. Ochsner, who
has had such magnificent results, should not
give his patients the full benefit of the doubt
and refrain from operating at this time. We
can almost surely eliminate danger by his
treatment. Why not wait then until the
proper (safest) time arrives? I think that this
point is a just criticism of the paper.

Another remark the doctor made struck me
forcibly, viz., when he termed calomel a "mur-
derous" remedy' in the treatment of appendi-
citis. I would like to tell the doctor what I
have seen calomel do. I have seen it save the
lives of two individuals suffering from ap-
pendicitis. In my opinion they we^e unques-
tionably saved by its use. I have a vivid men-
tal picture of them now — one a young man in
the city of Holland, the other a girl in tlie
village of Spring Lake, where I live during
the summer time. These cases had all the
symptoms and appearances of impending dis-
solution. The abdomen in each case was hard
and distended; pulse, rapid and thready; they
presented the hippocratic countenance; the
skin was clammy; death, in fact, was approach-
ing. This was before I had heard of Ochsner
and his work, years ago. and I do not believe
I would act now as I did then; but, still, those
two cases recovered. I said to the attending
physician I would not think of operating in
these cases, they would die certainly if we
operated; but we gave them large doses of



calomel with soda and they had tremendous
evacuations. They both recovered and are
alive and well to-day. Tliey not only tolerated
calomel, but they were benefited and saved, I
think, by its use. That goes to show that
there is no one plan that is the best for every
case. Whether the time will come when we
can be capable of scientific discrimination in
such cases I do not know. At present, how-
ever, we must use that plan which is asso-
ciated with the minimum of mortality.

The doctor did not mention the subject of
the incision, although I know he is a believer
in the McBurney plan. The surgeon should
not merely consider the present "conditions —
the matter of life and death — although that is
the chief aim; but he should also t;hink of the
subsequent matters, of the sequela, post-
operative hernia, etc., and therefore that oper-
ation or that incision which while giving the
operator ample opportunity to do his work,
will also tend to prevent hernia and obnoxious
sequela, is the incision to choose. The Mc-
Burney idea is a splendid one except in cases
of circumscribed abscess, where he himself
docs not recommend it.

Another thing comes to my mind which I
meant to discuss and that is the danger of
operating too soon after the acute attack.
Perhaps some surgeons can tell how soon
this may safely be done. I know that Dr.
Ochsner in other articles of his which I have
read states that within a few days after the
subsidence of the acute symptoms the opera-
tion can be done. Possibly it can be done by
him, but I think an error that these great oper-
ators fall into is that they think others can
do what they do. Now I believe that Dr. Ochs-
ner can do a great deal better operation than
I can and that perhaps he could save a life
whfere I might lose it. Possibly I might do
better than some fellow who has had less ex-
perience than I have had, and yet when these
great men promulgate a doctrine which they
know they can carry out, they do not recall
the fact that there are a good many, unques-
tionably thousands, of operators who can not
do as well, and therefore such a doctrine is
dangerous. Mere talk is not so convincing.
Experience tells the story. T remember a case
from Saranac which came to me — a case of
recurrent appendicitis in a young farmer. He
had a lump in the ileocecal region. This was
not an abscess. I have got far enough to be
able to tell sometimes what ^he nature of a
lump is, whether it is an abscess or not. This
Digitized by VjOOQIC



376



APPENDICITIS-OCHSNER.



Jour. M.S. M.S.



lump was adjudged a diseased appendix wrap-
ped about with omentum and the operation,
later, proved such to be the fact. Patient had
fever, increased pulse-rate, tenderness, nausea,
muscular rigidity, etc. We immediately put
him upon the so-called starvation plan and he
began to get better right away. In the course
of a week the pain on pressure had all gone;
even the tenderness had disappeared; his pulse
was normal. At that time we gave him a
dose of salts, which cleared his bowels out
well and left him still painless. I then
thought, as this had not stirred up any trou-
ble, it would be safe to operate; so I operated.
No pus was found. The appendix was sur-
rounded mostly by the omentum, a bit of the
ileum adherent to it. The operation was done
a la mode, but the man died of septic peri-
tonitis about three days later. This case was
drained, but it did not save^ him.

Another point, that of orrho- or sero-ther-
apy. As I said a few minutes ago, I have
never seen a case of septic peritonitis, arising
from appendicitis, recover, but 1 have seen
general septic peritonitis from another cause,
viz., dyo-salpint. cured by the use of the anti-
streptococcic serum, viz., a case of peritonitis
following the removal of a pus-tube in a darkey
girl — one of those chocolate colored individ-
uals who have no resistance anyway. The
darker a colored person the more resistance
they have; jiiixi'd breeds dont's have resist-
ance. This was a young mulatto girl who got
septic peritonitis rapidly subsequent to the re-
moval of the pus-tube, and while she was prac-
tically dying, with a pulse of 180, she recovered
through the influence of the anti-streptococcic
serum. It cured that case and if it cured one
it can cure others. It seems that there is a
field for this remedy in the future.

In closing I wish to state that I think Dr.
Ochsner is mainly in the right. As in the past,
so in the future, I shall continue to espouse
his principles.

Angus McLean, Detroit: As has been said,
where there is nothing great to be done, great
men are impossible. That would mean where
there is something great to be done a great
man is possible. When we stop, and think,
that within about three years there have passed
within the doors of the Augustana Hospital a
thou.sand cases of appendicitis and that all left
there well, but twenty-two, there must be a
great man there. Formerly we hoard much on
this subject all over the country. When I was



younger than I am now and went to the meet-
ings of the American Medical Association I
sat around in a back seat of the hall to see the
great men from the east, from the south, from
the north and from the west, discuss this sub-
ject and raise their hands, holler and exclaim
that every case should be operated upon when-
ever it was seen, regardless of the condition.
They had a death rate of 10 to 16 per cent.
Here we have listened to a paper, modestly
presented, with a death rate of 2J4 per cent.
That certainly must convince us all that the
conservative treatment is the proper one. Now
when a man can bring the death rate in appen-
dicitis down to three times as low as it is in
typhoid fever, down half what it is in measles,
down to almost what it is in chicken-pox, it is
difficult to get up here and criticise his man-
ner. He does not say that this is due to his
own manual dexterity, or any particular form
of technique. It appears he does not follow
any particular form. He judges the cases; the
technique follows in the separate cases. Now
it seems to be this: that it is not a matter of
. technique. We all know there are splendid
men all over the country whose technique dif-
fers but little. Then this must be due to the
judgment of the operator, and I think the
great success in the future has to come, and
the greatest progress is to be made, not along
the line of technique, but the line of more ac-
curate surgical diagnosis, to know when to op-
erate, more than a special method to follow.
Now, this has been accomplished by Dr. Ochs-
ner's method — call it what you may, element-
ary stasis, peristaltic quiesence, intestinal rest,
or whatever it may be, it seems to have been
his keynote of success. His greatest success
has been in the unoperable cases, in tiding
them over from the danger point, or tiding
them over from that point in which he con-
sidered that the disease had passed beyond the
outer wall of the appendix, holding them and
getting them into more favorable condition for
operation. That seems to be the one point,
that seems to he the secret, that seems to be
the principle by which he has reduced his
statistics to a minimum— a minimum that is
below any other statistics on the same subject
in this world. Now, when you stop to think,
that principle should not be so very strange
to us — should not be so very new to us. I
remember when T was a student if a person
got appendicitis, any form of peritonitis, in
fact any trouble in the peritoneal cavity, the
idea was to give him opium - rajid why> I
Digitized by VjOOQIC



Septembkk, 1904.



APPENDICITIS-OCHSNER.



3?7



think the reason was so that it would produce
a certain form of rest, a certain form of intes-
tinal quietude; and the same may be noticed
in opening an abdomen in which you will find
the omentum rolled around the appendix,
rolled around any organ there, which demon-
strates the fact that the omentum, if it can, its
disposition is to protect the whole area of
inflamed surface from the surrounding tissue.
It is evident that all it wants is the oppor-
tunity, and this idea of perfect elementary
rest, of perfect prohibiting of any sort of food,
gives the omentum an opportunity. Now it is plain
to me that this is the point upon which he has
built up those statistics. It seems to me this is the
point of which we should take notice. This partic-
ular form of treatment is within the reach of
everybody — within the reach of every physi-
cian, if he saw fit to use it. But this form of
treatment, this prohibiting of any food, if it
produces elementary stasis — if you wish to use
the word — that principle is within the reach
of every person, and I cannot see a bit of
harm, or why it cannot be tried in every case
that any physician should come across in
which there was a particle of doubt in his mind
as to what it was. I think the same principle as
he has applied here, restricted to appendicitis,
would be true of any intraparietal inflamma-
tion; that is, if you have peritoneal inflamma-
tion of any kind, surely you could bring about
the same result. If it will bring about thstt re-
sult of the appendix it Will bring it in the
omentum, ovary, or tube, or anything that lies
within that cavity.

So I want to say, without taking up more
time, that I wish to express myself clearly on
this point, and forcibly, for this seems to be
the Iceynote of his success. We will admit his
technique might be slightly better than other
operators, but he has not claimed that any part
of his technique adds to his success. It is this
sort of preparatory treatment. There is one
trouble in that, and that comes to the general
man, and that is that you can carry it out in
the hospital much better than you can in a
home of any kind, because it is almost impos-
sible to impress upon the parents or the people
in charge of keeping away strictly all food.
They say they can't see what harm a teaspoon
or a tablespoonful of water or a little bit of
milk or something will do and they will give
it to them, and if you follow it up and question
them closely you will find that something like
t|iat occurred.



I wish to extend my congratulations and
compliment Dr. Ochsner on these splendid
statistics.

J. H. Carstens, Detroit: What is there to
discuss when a man comes here and reports
a thousand cases of appendicitis with a death
rate of 2.2%? There is nothing to discuss.
We simply have got to bow our heads to the
superior skill, to the superior knowledge, to
the superior judgment of a master.

Many a discussion have I had with Dr.
Ochsner. I bearded the lion in his den. I went
over to Chicago and jumped on him, as the
boys say, right there— not because I did not
think he was right, but because I thought he
did not give the right kind of impression to
the general practitioners on this subject.
All over they said "Oh, I can starve pa-
tients," and they starved them, and starved
them, how? In a "namby pamby" kind of
way they starve them; not in a way as Dr.
McLean has just said, as it could be carried
out in the hospital. The result is a large
mortality, not because the treatment was not
right, but because it was not carried out prop-
erly. I claimed all the time that when you
had diagnosticated a diseased appendix the
only safe way for the patient was to have it
taken out, and that there was no danger in
taking it out. Dr. Ochsner told you the same
thing tonight — he agrees to that. When you
diagnosticate a case you should remove the
appendix if you can do it within the first 24
or 36 hours, before rupture has taken place.
He starves his patients, he uses judgment, he
does this, that or the other, just like every
other surgeon does, picks his time and oper-
ates when he thinks it is best. If the patient
is so weak, run down, debilitated and septic,
and the heart is so weak; no surgeon would
operate upon such a case as that. The pa- ,
tient might die on the table. He tries to
build that patient up and then he operates on
it. Now the trouble is and has been all tlie
time that the impression has gone about that
the treatment of appendicitis is a simple
thing, that they will recover if you starve
them. The laity even know about that; they
say "Oh, well, I have had that treatment of
starvation and I got over it, and I have got
my appendix yet.*' In a couple of months
they have another attack and they do the
.same thing. Some doctors encourage that
kind of treatment, and by and by, six months
Digitized by LjOOQIC



378



APPENDICITIS— OCHSNER.



Jour. M. S. M. S.



or a year, they have another attack. They
go through that with the same kind of treat-
ment, and they recover. Now, what are the
results? They are in danger that sometime
they may have these attacks of septic peri-
tonitis where even Dr. Ochsner has had
30% of mortality, and secondly, they are
constant invalids. They go around — oh, in
a little pain; can't do very much work; get
secondary troubles, disturbance of digestion,
disturbance of the stomach and nervous con-
ditions, neuresthenia and so on, simply be-
cause the appendix 'is not removed. "Oh
well," they say, "that is hot very serious, that
appendicitis. I got over it easy; I was
starved." That is the trouble, and that is
where I have had my fight with Dr. Ochsner.
But now you see, that he reads his paper, it
is clear; there is no question about it at all. ^
He says if you get tile 'cases early enough —
he don't get them early generally — but he
says if you get them early enough take the
appendix out; if you don't get them early and
they have general peritonitis, starve them,
rest the bowels and then take the appendix
out. He does not let one escape from his
hospital; he has got them all, and he takes
the appendix out. You see then, gentlemen,
we finally agree all right; great minds always
in the same channel run,

A. J. Ochsner, Chicago: In the first
place I will thank the gentlemen very heartily
for the discussion they have given me. The
points that were made are all very appropri-
ate. I will answer these various points very
rapidly, so as not to consume much time.

I must thank Dr. Carstens particularly for
his discussion here and for his former dis-
cussions, because his discussions and those
of some of the other men, particularly those
of De Vorr and some of the most radical
men, have served to cause the general prac-
titioner to read over those conclusions. I
have placed my position on appendicitis in
very definite conclusions, so that they could
be looked over without compelling the prac-
titioner to read a volume. And just as these
discussions have brought out the facts, and
as I have said over and over again, giving a
little liquid food is a dangerous thing, there is
no doubt but what a number of people have



died because my position was misunderstood.
I have no doubt but what there are many now
living who would be dead had it not been for
their following these conclusions accurately.
In other words, if they are not followed ac-
curately they are a dangerous thing to follow
at all.

Regarding all of these other points that
were made by Dr. McLean, and the points
of criticism that Dr. Graves made, and the
points that Dr. Dodge made, they are all very
well taken, they are all in that same direc-
tion. You cannot expound or establish any
particular treatment in so dangerous a dis-
ease as" appendicitis without leaving some
points open which will result in a certain
amount of mortality. I have brought that
out in my paper.

}. I will say one thing about the streptococcus
infection, because that has been mentioned
many times. Now in. streptococcus infection
of the extremities we have found that an in-
fection will become limited within a few days
if we simply place the extremity at rest. We
have a localized abcess; if we open it and
then place the extremity at rest we have
found that the streptococcus is one of the
easiest microbes to commit suicide. You
keep the streptococcus confined to any defi-
nite region and very soon he becomes inact-
ive, and I believe that by causing rest, even
in a streptococcus infection, a patient will re-
cover, when that same patient would not re-
cover if you made an abdominal section. So
I believe that this same principle can be em-
ployed here. There is a question that has
been set up, namely, as to whether I believe
that the appendix should be removed when
one opens the peritoneal cavity for the re-
moval of other conditions. I believe if the
appendix is long and is liable to become ad-
herent to the surface from which these other
tissues have been removed, that it should
always be removed instantly; that is, although
there may be no disease in the appendix it-
self. If there is no danger of such an ad-