APPENDICITIS: 
A TIMELY OPERATION. 
HOWARD CRUTCHER, M.D., CHICAGO. 
BY 
Professor of Surgical Anatomy and Principles of Surgery in the Hering Medical 
College of Chicago; Surgeon to the Hering Hospital. 
The following case is reported for several reasons. In the 
first place, it emphasizes once more, if more emphasis were 
needed, the treacherous character of appendicitis. In the 
next place it confirms, what is now universally admitted by 
rational witnesses, that there are no physical signs that 
possess the slightest value in determining the actual pathology 
of a given case. Finally, it shows very conclusively what 
splendid results can be obtained from the practice of modern . 
surgery. 
One night, not long ago, I was aroused by Dr. Amos C.. 
Hall, of Grand Crossing, who informed me that he had in handi 
a case of appendicitis which he desired me to see with him at 
an early hour the next morning. Supposing that the case might 
be in need of immediate assistance, I offered to go at once, but 
was assured by Dr. Hall that theie was no occasion for inter- 
ference before morning. 
At 8 a. m. the next day we saw the patient, a railroad 
conductor, aged thirty-four, and a man of magnificent physical 
development, who was nearly six feet tall and weighed one 
hundred and seventy-five pounds. For the past few years 
he had occasionally felt pain which he located rather vaguely 
in his “side.” This pain proved to have come from the right 2 
APPENDICITIS. 
iliac region. Five days before my examination, on the pre- 
ceding Sunday, he had suffered so much from pain that he was 
compelled to leave his work and take to his bed. Monday he 
was better, and Tuesday he was on the street but not attending 
to business. The next day (Wednesday) he was attacked with 
violent spasms of pain which sent his pulse and temperature 
up beyond the hundred point. Dr. Hall was called in the after- 
noon, administered the usual remedies, but without substantial 
benefit, and came for me about midnight. The patient suffered 
a great deal during the night and gave his attendants no rest. 
As before stated, I called for the first time Thursday morning 
at eight o’clock. 
The patient was, to all superficial appearances, much better; 
his pulse had fallen to 80; the temperature had dropped from 
103° to 99.50; the acute pain had gone. Moreover the bowels 
had moved copiously, and this would of itself have been highly 
conclusive to those amiable “ sweet oil ” and “ sweet water ” 
practitioners whose treatment of inflammatory diseases of the 
caecal region ought to be suspended until they study the 
anatomy and pathology of the region involved. I outlined 
carefully the caecal point and gave a sharp thrust over it with 
the tip of my index finger. The patient jumped and groaned 
with pain. 
Being asked for my opinion, I said: “I know nothing of 
the actual condition. The subsidence of the pain may mean 
prompt recovery. It may indicate gangrene and death within 
two days. One thing I can say most positively. His chances 
are infinitely better with the appendix outside than inside.” 
Dr. Hall most cordially approved this opinion and urged 
upon the patient the greater safety of an immediate operation. 
The sufferer readily consented. He was glad to be on the 
safe side. 
It was two o’clock before all of my assistants arrived, but 
the time spent in waiting was utilized in the preparation of the 
patient, the boiling of linen and the sterilizing of the room. 
The patient was given a large saline enema, a general bath, 
and otherwise prepared for the operation. 
Everything being in readiness, I began the operation by 
what I call the high incision, namely, following the trend of APPENDICITIS. 
3 
the external oblique, nearly midway between the iliac point 
and the umbilicus, but above the imaginary line connecting 
those two landmarks. I fancy this incision gives far less 
haemorrhage than the lower incision, as I now recall that in 
three operations within three weeks, I have not applied a 
ligature or used torsion upon a single vessel, in the line of 
incision. A heavy layer of adipose tissue rendered a three- 
inch incision necessary. The skin and each layer of the 
abdominal wound was secured by silk ligatures as soon as 
divided by the knife. This procedure is necessary in order 
that the various layers may not retract beyond reach during 
the operation. The peritoneum was very thick and deceptive. 
The adhesions were firm and abundant. I found the appendix 
firmly adherent along its mesenteric border and separated it 
from its bed with considerable effort. The external appearances 
of the appendix were not especially pathological. It was quite 
red, about as large in diameter as an ordinary one-drachm round 
vial and perhaps five inches or more in length. The base was 
secured with fine chromic catgut and the tube cut away at a 
safe distance from the ligature. The stump was very large and 
the caecum was so pointed that it was practically impossible 
to tell where the caecum left off and the appendix begun. For 
this reason, I did not, for once, burry the stump, as I feared 
to impinge too much upon the lumen of the caecum. Beginning 
at the lower angle of the peritoneal cut with a long catgut 
suture I united the five layers by continuous sutures. 
The repeated use of the catheter aroused some traumatism 
on the sixth day, which sent up the pulse and temperature, but 
beyond this the recovery was uneventful. The wound united 
perfectly by the fifth day, leaving a fine scar that time will do 
much to obliterate. 
I now return to the appendix. The probe passes into a 
healthy lumen at the base and proceeds for an inch, where it 
encounters an impenetratable stricture. Slitting the appendix 
along the free border we notice its sudden partial collapse. 
For fully three inches the mucous membrane is gangrenous and 
gives forth a foul and sickening stench. Within an inch of the 
tip was another stricture, beyond which the lumen was healthy. 
This, then, was the condition: The base and the tip, each for APPENDICITIS. 
4 
about an inch, perfectly normal; the central segment gan- 
grenous and ballooned with the gaseous products of decay. 
It was like the hood of the cobra and was charged with poison as 
deadly as the vemon of that well-known and terrible reptile. 
There was no concretion or obstruction of any kind found within 
the lumen of the appendix. As to the formation of the strictures 
and the cause of the gangrene, I have no idea whatever. That 
an explosion of those confined gasses was inevitable, and that a 
fatal infection of the peritoneum would have followed, is 
perfectly apparent. My judgement is that the patient would 
not have lived seventy-two hours without surgical relief. 
Now, will any sane man of experience claim that therapeutic 
measures would have lengthened this patient’s life a single 
hour ? Would sweet oil or olive oil or rain water or sweet 
■cider or any other liquid have removed that stricture ? And 
if so, where is the case recorded in which those fluids have 
cured gangrene ? The truth is, the olive oil practitioner would 
have pronounced his patient better on the day the operation 
was performed and would have buried his patient along with 
his blunder a few days later. This patient owes his life to the 
diagnostic skill and sound judgment of Dr. Hall, whose 
hesitation or ignorance would have cost his patient his life. 
My experience, while not so extensive as that of some, 
certainly entitles me to speak with some confidence as to the 
management of these cases. Within a few months I have seen 
probably twenty-five cases, some medical, some surgical, and 
this fact has been demonstrated, beyond the shadow of a doubt: 
that the foolish and irrational expedients that are so commonly 
recommended in this trouble, poultices, enemas, etc., are not 
only useless but positively injurious. They mask the condition 
and mislead the surgeon. Appropriate medicines will relieve 
promptly all curable cases; and when therapeutic measures 
fail to give relief it is an undoubted indication for immediate 
surgical interference. 
There are, of course, those who believe that medicine will 
cure everything, and their> testimony is almost as reliable as 
that of those who assert that medicine will cure nothing. 
Most of us are human; we are not blessed with an unlimited 
knowledge of an infallible materia medica, as some are, and APPENDICITIS. 
5 
we must do the best we know how. When our best efforts at 
therapeutics have failed, we had better forget ourselves for a 
time, save our patient and argue the case later. 
Appendicitis differs from most diseases in that its true con- 
dition is masked; many lesions of the brain are as clear as 
sunlight when compared with the changes in the caecal region. 
The sportsman who drops his hook into thirty feet of muddy 
water and guesses from the impulse communicated to his rod 
what sort of fish he has caught on his line is likely to be correct 
once in a while, but it will be generally admitted that his task 
is easy compared with that of the physician who attempts 
accurate diagnosis in appendicitis. It is, in short, impossible. 
The mortality from primary appendicitis is given at 12 per 
cent, that is, one in eight. Here are eighty-eight recoveries, all 
of whom oppose operation; the other twelve are in their graves, 
and are therefore not present to advocate either medicine or 
surgery; the vote is necessarily cast unanimously against 
operation. “ Are we not an overwhelming majority ? Have 
we not had appendicitis? Did not medicine cure us?” This 
is the town-meeting plan of deciding scientific questions. But 
the twelve dead are surely entitled to some consideration. There 
are, it is true, eighty-eight living, but they are booked for succeed- 
ing attacks, more dangerous than the first, and each attack 
is sure to decimate their ranks more disastrously than the one 
preceding. If all had been operated upon at the first symptoms 
of acute inflammation about ninety-nine would be alive instead 
of eighty eight, a clear gain of eleven and a positive assurance 
against all future attacks. 
In conclusion I may present some rules for general guidance 
that I think will prove reliable: 
1. —The pulse and temperature are not safe guides as to the 
local condition. 
2. —Cessation of pain may indicate either approaching 
recovery or impending death. 
3. —Where acute pain is aroused by digital pressure over 
the cmcal point, operate at once. 
4. — “ Early operation ” means before pus has formed. 
5. —When pus has formed do not invade the peritoneal 
cavity unless such a course is imperatively demanded. 6 
APPENDICITIS. 
6. —Medical cases are relieved promptly by appropriate 
remedies; surgical cases ought to be relieved as promptly by 
surgery. 
7. —To allow a gangrenous appendix to butcher a patient is 
worse than any abuse charged against surgery. 
8. —One attack of appendicitis invariably predisposes to a 
second attack. 
9. —Succeeding attacks are increasingly dangerous. 
10. —A mistake on the side of non-interference gives the 
patient seven chances out of eight; a mistake on the side of 
interference, if mistake is ever made on that side, gives the 
sufferer forty-nine chances out of fifty. 
11. —When in doubt, operate. 
Whilst I do not believe that one man’s exprience should 
count for more than it is worth, I state it as a fact that all of 
my late operations (those with pus, preforations, gangrene and 
general sepsis) have died, every one of my early operations 
have recovered. 
103 State Street. 
Reprinted from The Medical Current for October, 1804.