Reprinted from 
Annals of Gynecology and Pediatry, 
May, 1892. 
The Treatment of Appendicitis. 
BY A. WORCESTER, A.M., M.D., 
WALTHAM, MASS. The Treatment of Appendicitis. 
BY A. WORCESTER, A.M., M.D., 
WALTHAM, MASS. 
The appendix vermiformis is, so far 
as is known, a useless organ. This is 
very likely the reason of its proneness 
to decay. Any inflammation of it is 
likely to become gangrenous in charac- 
ter, and to result in the partial or com- 
plete obliteration of the organ. This 
is Nature's method of treatment. But 
grave dangers attend this natural 
process. Either by direct extension 
of the inflammation, or by infection 
from the perforated bowel, there is 
likely to result a circumscribed peri- 
tonitis, a localized abscess, or a diffuse 
purulent peritonitis. 
At the beginning of an attack of 
appendicitis it is easy to make the 
diagnosis, but not possible to foretell 
whether the inflammation will quietly 
subside or will result in one of these 
complications. And if the attack 
does quietly subside, the patient is 
afterwards very liable to successive 
attacks, each more likely to result 
disastrously. 
There is only one logical treat- 
ment of the disease, namely, the ex- 
cision of the diseased organ as soon as 
the diagnosis is made. No other 
intelligible rule can be formulated. 
If followed, the disease now so 
dreaded will be robbed of its present 
fearful fatality. 
To demonstrate this proposition it 
is only necessary to establish the 
verity of the statements I have already 
made and to show the absolute safety 
of the operation advocated, and this I 
propose to do. 
No one, I suppose, will contend 
that the appendix is of any use, or 
that its removal is the slightest dis- 
advantage. Nor will any one now 
dispute the statement that the ap- 
pendix is prone to inflammation, which 
is liable to become gangrenous, and 
thus cause serious complications. 
There may be some who feel them- 
selves able to decide at the beginning 
of a given attack of appendicitis 2 
A. WORCESTER. 
whether it will prove to be of the mild 
and comparatively harmless or of the 
dangerous kind. 
Many writers on the subject have 
attempted to lay down rules for mak- 
ing this distinction. But there is no 
uniformity among such writers, nor is 
there any consistency ; their opinions 
are undergoing evolution. Most sur- 
geons and nearly all physicians still 
cling to the frightfully unjustifiable 
policy of waiting for time to deter- 
mine this question. With never a 
twinge of self-reproach they keep 
reporting cases of appendicitis where 
the patient's life was endangered or 
even sacrificed by their Fabian policy; 
and, because they can also report 
cases where the attack proved to be 
of the mild, harmless sort, they de- 
claim against the men who operate in 
every case. 
It is, however, very plain that these 
advocates of the waiting and watch- 
ing policy are learning to watch more 
closely and to wait less and less. 
In their laudable efforts to discover 
the signs of the proper time for sur- 
gical interference they are hurrying 
towards the only logical position. 
Even now the most experienced look 
forward longingly to the comfort of 
finally being able to stand on both 
feet in the presence of this heretofore 
dreaded disease. Some surgeons, 
who, even a year or two ago, were 
describing the advantages of operating 
on the fourth day or on the third day, 
are now admitting that the time for 
operating is not to be estimated in 
days, but is to be determined by the 
undoubted presence of pus in the 
neighborhood of the appendix. When 
such surgeons have taken the next 
step forward, and will allow that the 
time for operating is when there is an 
undoubted circumscribed peritonitis, 
they will find themselves at last on 
sure footing. For without the pres- 
ence of a circumscribed peritonitis it 
is probably not possible to diagnosti- 
cate appendicitis. If it is possible, 
then still will the rule hold to excise 
the appendix as soon as ever the 
diagnosis of its inflammation is made. 
In such case the operation will be 
even easier; not more safe, for the 
operation, if performed even as soon 
as the diagnosis is established by the 
onset of a circumscribed peritonitis, 
is an absolutely safe operation. To 
this, however, I shall recur. 
Let us first consider the reasons for 
objecting to my rule. 
(i) There is still in the minds of 
many a confusion of the disease ap- 
pendicitis and of its sequelae. The 
pathologists have taught us that peri- 
typhlitic abscesses are usually caused 
by appendicitis. This should influ- 
ence the treatment of appendicitis 
only by making us more zealous to 
prevent a perityphlitic abscess, by re- 
moving its cause. Few practitioners 
have yet recognized this logical neces- 
sity. And it is still commonly held 
that the treatment of these entirely 
different conditions should be the 
same. Why? Because, forsooth, the 
abscess is the result of the appendi- 
citis. More sensible would it be to 
declaim against the excision of a dis- 
eased Fallopian tube because its prob- 
able sequel, a pelvic abscess, can occa- 
sionally be best drained per vaginam ; 
for in this case even the slough- 
ing of the tube does not directly 
threaten a vital organ, whereas the 
sloughing of the appendix threatens 
the integrity of the intestine. 
But even admitting, for the sole sake 
of routing the Fabians, that the treat- THE TREATMENT OF APPENDICITIS. 
3 
ment of the two conditions should be 
the same, even so they have no suf. 
ficient reason for delaying the use of 
the knife. It is true that in cases of 
distinctly localized perityphlitic ab- 
scess there is much less danger of dif- 
fuse peritonitis ensuing than there is 
in cases of appendicitis proper. There 
is, therefore, less danger in delaying 
surgical interference. But it is a mis- 
take to suppose, as many surgeons 
persist in supposing, that there is any 
safety in thus delaying. The abscess 
may become attached to the abdomi- 
nal wall, and its foul contents may, 
indeed, burrow through it; but the 
chances are greater that, if not origi- 
nally so attached, it will never be so. 
And while the surgeon is waiting in 
the hope of a shorter cut, the pus 
is very likely to make one of its own 
not at all to the surgeon's liking. 
Moreover, even if unattached to the 
abdominal wall, a perityphlitic abscess 
presents no great difficulty to a mod- 
erately skilful operator. After incis- 
ing the abdominal wall and packing 
protective sponges or gauze around 
the abscess, it can be evacuated with- 
out infecting the general abdominal 
cavity. And then, if the operator is 
content to let the sloughing tissues 
come away of their own accord, sim- 
ply packing the cavity with gauze and 
not undoing his good work by sewing 
up the abdominal wound, then the 
patient will do surprisingly well. 
Here, for example, is a case of this 
kind-one of three in which I have 
operated during the past month, all of 
which have done equally well. 
old, of slender build, but strong and 
healthy, thought she "took cold" the 
morning of April 7, 1892. She had 
been wrestling with her sister, and sat 
for some time afterward outdoors, till 
quite chilled. She ate no dinner that 
day, and complained of fatigue and 
of pain in her left side. She gave out 
at her work the next day, but the day 
after she resumed her place at the 
counter, though still suffering pain, 
especially after any body-motion. 
During the following few days she 
grew more tired, but kept at work. 
She took salts, as was her habit, and 
secured a thorough evacuation of the 
bowels. I first saw her at 9 p.m., April 
13, the sixth day after the first attack 
of pain. She complained of pain in 
the left side above the waist, but on 
close questioning she referred the 
pain also to the right hypochondriac 
region. There was slight tenderness 
in the right iliac fossa, where a small 
lump could be felt. Her temperature 
was 1010, her pulse 100. Poultices 
were ordered. The next morning at 
9 o'clock her temperature was 990, 
pulse 84. The tumor had increased 
slightly in size toward the median 
line. It was not very tender, but was 
dull to percussion and well defined. 
Operation.-An incision two inches 
long was made through the thin ab- 
dominal wall, directly over the tumor. 
The peritonaeum was found to be nor- 
mal. A mass the size of a hen's egg 
presented, at the lower end of which 
the root of the appendix could be felt. 
Sponges were packed toward the me- 
dian line. In searching with the fin- 
ger for the most vulnerable point in 
the mass, the abscess cavity was 
opened, allowing the escape of foul pus. 
After washing out the cavity it was 
packed with iodoform gauze. Recov- 
PERITYPHLITIC ABSCESS, UNATTACHED 
TO THE ABDOMINAL WALL.-OPER- 
ATION.-RECOVERY. 
Miss M., a saleswoman, 21 years 4 
A. WORCESTER. 
ery was rapid and uneventful. The 
next day and thereafter her tempera- 
ture was normal. In two weeks she 
was sitting up nearly all day, although 
the abdominal wound had not entirely 
healed, its edges being drawn together 
with lacings, passed between belaying 
pins, which were fastened to the ab 
dominal walls by adhesive plaster. 
Now there is nothing remarkable 
about this case, nor will there usually 
be in similar cases if treated surgi- 
cally. There was no pressing need 
for the operation, and perhaps she 
would have recovered without it. 
But I was too timid to take the re- 
sponsibility of the risk that there 
always is in delaying to evacuate an 
internal abscess; and a cake in the 
right iliac fossa, tender to pressure, 
in a patient even slightly feverish, 
means an abscess. As for the risk 
attending the operation, that counts 
for nothing, for it is less than the 
risk there is in waiting Micawber- 
like. I maintain, therefore, that the 
proper treatment of a perityphlitic 
abscess is its immediate evacuation 
by means of the knife. But what- 
ever opinion is held about the treat- 
ment of this complication or result, 
such opinion has no proper place in 
discussing the treatment of appen- 
dicitis itself. 
2. Another objection to my rule of 
operating, as soon as ever the diag- 
nosis of appendicitis is made, is 
founded upon the inexperience of the 
most eminent surgeons with the very 
beginning of the disease. Never 
having had the opportunity to operate 
at the proper time, they naturally 
hesitate to adopt the experience, how- 
ever favorable it may have been, of 
those who have had such opportuni- 
ties. 
3. Then there is the objection, 
founded upon the common experience, 
of having patients die who were mori- 
bund at the time of the operation. 
Such cases still enter the statistics, 
accredited not where they belong- 
to the almost criminal folly of the 
Fabians, but to the luckless surgeon 
who was, perhaps, summoned only 
when the patient's pulse could not 
be counted at the wrist. 
4. Finally, the objection is made to 
my rule that to be bound by it one 
must disregard the many mild cases 
of appendicitis that do very well if 
left alone, or if treated medically. 
This is the only objection worthy of 
serious consideration. It involves 
the fundamental question of the diag- 
nosis of the disease. I do not main- 
tain the duty of operating in cases of 
suspected appendicitis. I am con- 
stantly seeing such cases, and I sup- 
pose every general practitioner nowa- 
days is suspecting appendicitis many 
more times than he actually finds it. 
Indeed, this must be so, if he employs 
the eliminative method of diagnosis. 
In many of these cases where an ap- 
pendicitis is a possibility, it may be 
impossible to exclude it. It may be 
true that I ought, in my list of cases 
of appendicitis, to include many of 
these bellyaches, where I could not 
be sure that there was not some ca- 
tarrhal inflammation of the appendi- 
cular mucous lining, or some rheuma- 
tism of the muscular walls. However 
misleadingly I may have omitted such 
cases, my ignorance must excuse the 
omission. I can only assert that 
never, since my own recovery from 
the disease, after a late operation four 
years ago, have I failed where the 
responsibility rested upon me, to 
follow the rule herein maintained of THE TREATMENT OF APPENDICITIS. 
5 
operating as soon as ever the diag- 
nosis is made. 
In order to establish the rightful- 
ness of the rule it is necessary, as 
was stated above, to show the abso- 
lute safety of the operation. This 
can be done only by the slow accu- 
mulation o'f the reported experience 
of those who follow the rule. Cases 
where the operation is for any reason 
.delayed after the diagnosis is made, 
must not, in this connection, be con- 
sidered; and, therefore, there are as 
yet only a comparatively few cases 
for our consideration; but, so far as I 
have been able to discover, no case 
has yet been reported where the im- 
mediate operation has resulted badly, 
either as regards the recovery of the 
patient, or as regards any unfortunate 
after effects. Nor have I found any 
case reported where the operator 
failed to find full justification for 
operating in the threatening condi- 
tion of the appendix. Whereas, in 
many of the cases, where outwardly 
there was little evidence of the neces- 
sity for surgical interference, the in- 
ternal conditions were found to be 
such as were certain to have caused 
dire results to the patient if not death 
itself. I have myself been able to 
report several such cases1, where I 
succeeded in amputating the gangre- 
nous appendix before it became per- 
forated and before there was a drop 
of pus in its neighborhood; where 
there was no surrounding abscess 
wall to exclude from the general ab- 
dominal cavity the fearfully foul dis- 
charge that soon would have occurred 
through the rapidly dissolving wall 
of the appendix; but, instead, only 
cobweb-like adhesions between coils 
of intestines in the neighborhood. 
No one who has ever operated in 
such a case-after experiencing the 
ease with which the offending organ 
can be found, brought up through the 
abdominal incision, and there ex- 
cised-would hesitate in choosing the 
earliest possible occasion for operat- 
ing, so far as his own convenience and 
the safety of the operation is con- 
cerned. 
The first case, so far as I am aware, 
in which this early operation was done 
was briefly reported by my colleague, 
Dr. E. R. Cutler, to the Boston So- 
ciety for Medical Observation, Jan- 
uary 7, 1889, and published in the 
Boston Medical and Surgical Journal 
for June 6, 1889. 
The diagnosis in that case was 
made from the presence of pain and 
tenderness in the right inguinal 
region, accompanied with fever. 
There was no resistance to pressure, 
or dulness on percussion. The opera- 
tion was performed at the end of 
forty-eight hours. The gangrenous 
appendix was easily found. There 
was no pus in its neighborhood. It 
was amputated, and the patient made 
a perfect and speedy recovery. He 
left the hospital and journeyed by 
railroad twenty miles to his home, on 
the fourteenth day after the operation, 
and has since been a perfectly well 
man. 
The appendix in this case had al- 
ready become perforated, probably, al- 
though in manipulating it into view 
its thinned, friable walls may first 
have suffered perforation. 
The brilliant result in this case had 
great influence in determining the 
treatment of our subsequent cases. 
Of the twenty-one cases I have since 
1 See, for instance, Case No. Ill in the Boston 
Medical and Surgical Journal, Vol. CXXII, No. 5, 
p. 98. 6 
A. WORCESTER. 
had the honor to report,1 in eight 
cases the appendix was amputated be- 
fore it had perforated. In four other 
cases where the appendix was re- 
moved it was found to be perforated. 
In only one of these cases was there 
a fatal result, and in that case (June, 
1889) operation, though strenuously 
urged, was not allowed by the pa- 
tient's family until after several days' 
delay. Such a case should not be 
considered in discussing the advan- 
tages of immediate operation. In a 
similar case I should not now consent 
to share with the family the respon- 
sibility of delay. 
of a useless organ, dangerously sit- 
uated. 
(2) At the beginning of an attack 
it is not possible to determine 
whether it will prove of the harmless 
or of the dangerous kind. 
(3) The diagnosis is easy in com- 
parison with the task of diagnosticat- 
ing the seat of any acute inflamma- 
tion. 
(4) At the beginning of an attack, 
the excision of the appendix is an 
easy and a perfectly safe operation. 
(5) If so treated, all complications 
and all subsequent attacks are avoided 
(6) In view of the results already 
obtained by following this treatment, 
no other treatment is worthy of con- 
sideration. 
Summary. 
(1) Appendicitis is an inflammation 
1 Twelve cases were reported to the Surgical Section 
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