Reprint from The Nashville Journal of Medicine and Surgery, 
July, 1897. 
OPERATIVE INDICATIONS IN APPENDICITIS* 
CHARLES S. BRIGGS, A.M., M.D., NASHVILLE. 
Probably the most puzzling question that confronts the 
medical profession of to-day is, ' ' When shall we operate for 
appendicitis?" With the great body of physicians, possibly, 
the question assumes a different form; as, "Shall cases of 
appendicitis be turned over to surgeons for operation ? ' ' 
It is true that at the present time the number of physicians 
who doubt the necessity of operative interference in appendi- 
citis under any circumstances grows smaller from day to day. 
Yet there is a class of practitioners who, because they have 
had undoubted cases of appendicitis to recover without opera- 
tion in their hands, vigorously oppose operative interference 
in all cases. When the medical world learns to regard the 
disease as one essentially belonging to surgeons, the question 
will doubtless be less difficult of solution. 
Surgeons are now pretty generally advocating earlier and 
more frequent resort to operation. It is almost accepted as an 
axiom in the surgical world that the most rational and scien- 
tific treatment of appendicitis is the removal of the appendix. 
Richardson, of Boston, writes: "Without doubt the best 
treatment, could it be applied in the first hours of the disease, 
would be immediate exploration and removal of the appendix." 
Pozzi, in the February number of Annals of Gynecology 
and Pediatry, says: " Every time that an appendix gives rise 
to local or general symptoms, no matter how severe they may 
be, the organ should be removed without delay. Either these 
accidents will immediately put the patient's life in danger or, 
if they momentarily get better, they leave the patient with an 
infirmity which is often disagreeable and always menacing. ' ' 
*Read before the Middle Tennessee Medical Society at McMinnville, 
Tenn., June 18, 1897. 2 
Fowler writes: "As soon as a positive diagnosis of pro- 
gressive appendicitis is assured the abdomen should be opened 
and the appendix removed." 
Morris writes: " There are no groups of symptoms which 
will allow us to make a rational prognosis as to the eventual 
outcome or the prospective complications in any progressive 
case of appendicitis, and we must abandon hope of having any 
such classification of symptoms for a guide in the future." 
The same author, in his treatise on appendicitis, says in his 
Characteristic way: " There is but one rule to be followed, and 
that is to isolate an infected appendix as promptly as we would 
isolate a case of diphtheria. An infected appendix is isolated 
when it is out of the patient." 
Deaver, in his work upon Appendicitis, writes as follows: 
"Although there may be a few cases that for one or all the 
reasons stated cannot, or will not, have the benefit of early 
operation, yet the vast majority will depend upon the physi- 
cian for advice. In every one of these, unless constitutionally 
contra-indicated, I believe that the appendix should be removed 
as soon as the diagnosis has been established. I recognize the 
fact that a very small percentage of all cases will temporarily 
recover without the use of the knife, but no one can tell which 
case will terminate unfavorably, or which will go on to perfo- 
ration and gangrene, with the train of fatal complications that 
is liable to follow. The best result in all cases is obtained by 
removal of the appendix in the beginning of the attack. . Ap- 
pendicitis is a surgical affection, and should be treated as 
such." 
The foregoing are the opinions of a few of the most enthusi- 
astic advocates of early and frequent operation in appendicitis. 
The success following the operation in the hands of surgeons 
experienced in this line of work is wonderful. Operations 
performed in the early part of an attack of the disease give a 
mortality of only half of one per cent. A stumbling-block in 
the way of the more general adoption of the operation in all 
cases is the fact that a large majority of cases apparently 
recover without operation. 
Bwald, in an article on appendicitis in volume ix. of The 
Twentieth Century of the Practice of Medicine, writes; "Accord- 3 
ing to the experience of general practice and the statistical 
results of Sabli, Rennis, Gaitman, Leyden, Furbrineger, Hol- 
lander, Rothe, and the majority of French physicians, from 
90 to 91 per cent, of all cases of perityphlitis, taken in the 
widest sense, recover without any operation. ' ' 
It must be admitted that such a small mortality rate is 
something of an argument against the operative treatment of 
the disease at first glance, but it loses force when we consider 
the fact that we can never in any given case say positively 
from the symptoms that recovery will take place. 
Bwald says in the above-quoted paper: "We do not pos- 
sess one single reliable symptom by which we can estimate the 
gravity of the process, i. e., its probable course.'' 
Fowler says: "There may be almost normal pulse-rate and 
temperature, and yet ulceration, perforation and impending 
peritonitis. ' ' 
The writer has operated on cases in which the peritoneal 
cavity was filled with pus, and yet in which there were no 
symptoms of the serious conditions of things. In one case of 
the kind the patient was placed on the table with a pulse of 
88 and a temperature of 990. 
It is just this absence of correspondence between the pre- 
senting symptoms and the gravity of the lesions in appendi- 
citis that renders the necessity of operative interference uncer- 
tain. We can by no means feel assured in any given case 
whether the disease is simple catarrhal or suppurative. We 
have no reliable guide as to the actual condition of the parts 
involved. A tumor in the right iliac region frequently devel- 
ops in the later stages of appendicitis, but its presence does 
not mean necessarily pus formation, nor does its absence indi- 
cate that there is no abscess. Other symptoms commonly 
observed-such as persistent pain and tenderness in the groin, 
accentuated tenderness at McBurney's point, rigidity of the 
right rectus muscle, vomiting, diarrhoea or constipation-how- 
ever accurately interpreted, shed no more light as to the real 
status of the intra-abdominal trouble. In my own experience 
I have found it more difficult to decide when operation might 
be dispensed with or deferred than when it was imperatively 
demanded. It is a safe rule to operate when in doubt. It is 4 
better to err on the safe side than on the wrong, and all will 
agree that it is wiser to operate too early than too late. Most 
of the fatal results have occurred when, from circumstances or 
from mistaken conservatism, operation has been delayed too 
long. I cannot recall a single fatal case in my own hands in 
which the result would not have been successful had the oper- 
ation been done a few hours earlier. If the conditions de- 
manding operation are not serious, the operation will not, in 
in proper hands, prove serious. On the contrary, if grave 
changes have taken place, the results are apt to be correspond- 
ingly grave. 
If it were possible to secure a skigraphic picture of the 
true state of the parts in appendicitis, I doubt not but that 
operations for its relief would be far more frequently per- 
formed. Here is the difficulty. No one can tell us how to 
make a differential diagnosis between the catarrhal and sup- 
purative form of the disease before an abscess has actually 
occurred. When that can be done the problem as to what 
cases should be operated upon will be solved. 
Nor can anyone say just what proportion of simple, uncom- 
plicated catarrhal cases of appendicitis will make a permanent 
and final recovery. It is well known that one attack of appen- 
dicitis strongly predisposes to recurrent attacks, any one of 
which is liable to assume the suppurative form. Is not this 
uncertainty of apparently simple catarrhal cases a sufficient 
argument for early operation in every case? Granting that 
the surgeon who operates in every instance does an occasional 
unnecessary operation, when it is considered that such opera- 
tions in competent and experienced hands are as nearly abso- 
lutely safe as any operation can be, and besides this, by prompt 
removal of the appendix patients recover once and for all from 
a serious disease, surely it cannot be said that such operations 
are unjustifiable. 
A material obstacle in the way of the general adoption of 
the rule to operate in all cases is the position of the general 
practitioner, who refuses to sanction early and universal sur- 
gical operation on the grounds that patients frequently make 
temporary recoveries from unmistakable attacks of appendi- 
citis. It would seem that the physician is loath to yield up to 5 
the surgeon a disease which he thinks belongs legitimately to 
him until the very last moment, when the hope of recovery, 
with or without operation, is infinitely small. 
Some writer has said that not a single therapeutic measure 
can be proved to exert any positive, decided effect upon the 
intra-abdominal lesions that take place in appendicitis. When 
infection has once occurred no medicine can delay its progress 
for a moment. The only remedy is surgical. Until, then, 
surgeons receive the ready and intelligent support of physi- 
cians, they cannot expect to be permitted to operate on every 
case, mild or severe. In my opinion, early operation and oper- 
ation in every well-marked case would be the safest procedure, 
and yet I recognize the need of the physician's acquiescence 
before this can be established as a rule. 
Interval operations-that is, operations done after the sub- 
sidence of acute attacks-are almost invariably followed by 
success, and, when circumstances permit, it is well to try to 
tide a patient over the dangers of the acute stage and operate 
in the interval; but it is difficult to get the patient's consent to 
submit to an operation of such magnitude when he has escaped 
the danger of an acute attack and is to all appearances well. 
Besides, in the uncertainty of acute attacks great risks are 
necessarily encountered, and the operation may be demanded 
by the progressive severity of the case. We are to study the 
symptoms, obscure and uncertain as they are, and operate 
when imperatively demanded, recognizing the fact that by so 
doing we are steering betweeen Scylia and Charybdis. 
In simple, uncomplicated catarrhal appendicitis explora- 
tory section of the abdomen and removal of the appendix is 
the most surgical remedy and the most positive cure. With 
medical treatment, cases of this class may recover, only to 
undergo, at different periods, recurrent attacks, any one of 
which may prove fatal. The symptoms of this class of appen- 
dicitis cases may be almost analogous to those attending the 
more severe cases of suppurative and perforating cases. When 
suppuration has occurred, the necessity for prompt interfer- 
ence will not be gainsaid. The difficulty here is that no one 
can tell when suppuration has occurred. Ewald, in his recent 
article in The Twentienth Century Practice^ advocates explo- 6 
ratory puncture to ascertain the presence or absence of pus, 
but this method has little to recommend it, inasmuch as it is 
not a little dangerous and if used is by no means an infallible 
test. 
In cases of appendicitis of progressive severity, in which 
the patient in his general appearance shows that he is seriously 
ill, and in which the pulse becomes progressively accelerated, 
gradually increasing in rate from 100 to no and 120, opera- 
tion is certainly indicated, and should be done. The temper- 
ature may be normal, it may be elevated or subnormal, but if 
the pulse-rate is gradually accelerated operation is the only 
safe remedy. When perforation has occurred, surely no one 
would advise against operation. Death is almost sure in such 
cases without operation. One would with as much reason 
argue against operation for the relief of strangulated hernia 
as against operation for an appendicitis in the course of which 
perforation has occurred. Can the surgeon with any degree of 
assurance say when this serious complication occurs? Accord- 
ing to most of the recent writers opinions as to the existence 
of this grave complication are based upon the gradual increas- 
ing gravity of the symptoms, but unfortunately the accident 
may occur without any accession of ugly symptoms. 
In all the voluminous literature written upon the subject 
of intestinal perforation in appendical inflammation during the 
last ten years, I find not a solitary reference to a sign that I 
regard as infallible as indicating the existence of perforation. 
I refer to the loss of the area of hepatic dullness from the 
escape of intestinal gases into the general peritoneal cavity. 
This valuable sign was first made known to the profession in 
an article by the late Prof. Austin Flint published in the Med- 
ical News, Saturday, July 4, 1885, entitled "On Persistent 
on Percussion Over the Diver as Proof that Diffuse Peritonitis 
is Not Associated with Intestinal or Gastric Perforation." In 
this paper the author referred to a number of experiments 
upon the cadaver which demonstrated that the injection into 
the peritoneal cavity of a moderate quantity of air causes the 
disappearance of the flatness in percussion over the liver which 
is normally present. In this article, in connection with the 
case of intestinal perforation from appendicitis, the author 7 
outlined the proper treatment for appendicitis with perforation 
in this language used in the paper: "The question maybe 
raised whether a free incision into the abscess might not have 
been advisable and the perforated appendix ligated. ' ' 
Tympanitic resonance over the liver does not invariably 
denote perforation, as it may be caused by an over-distended 
transverse colon, separating the abdominal walls from the 
liver; but persistent dullness over the liver is unmistakable 
proof of the non-existence of perforation. In my own prac- 
tice, I have learned to look for this sign in all cases of severe 
appendicitis, and in many operative cases have been guided 
by its presence. In no single case in which there was loss of 
the area of hepatic dullness have I failed to find perforation. 
It has proven invaluable to me in determining operation in 
severe appendicitis. It is absolutely reliable, and should be a 
prominent feature in the symptomatology of appendicitis. 
Associated with this important symptom is another which 
I have learned to regard as very useful in denoting grave 
intestinal lesions. I refer to the presence of an unmistakable 
fecal odor to the breath. In the later stages of severe appen- 
dicitis the presence of these two signs, in connection with 
other well-known clinical features, renders the necessity for 
operative interference in appendicitis absolute. 
In concluding this paper, which, I fear, has already trans- 
cended its prescribed limits, I will summarize as follows: 
Appendicitis is a surgical disease, and should be treated 
surgically. It is surgical to operate on every clearly-marked 
case of appendicitis in its early stage, especially if the disease 
shows a progressive tendency. If this were the general rule 
of practice, the mortality rate would be reduced to almost nil, 
always providing that the operations were done by skillful and 
experienced hands. If an expectant or medicinal plan of 
treatment is adopted, it should be carried out with a full sense 
of the danger of such a course the attendant being fully alive 
to the treacherous nature of the disease and ready at a 
moment's notice of danger, to substitute for such an expect- 
ant course, the more radical and more surgical method of 
removing the infected appendix. The expectant method may 
be selected in cases apparently mild, with the view of allowing 8 
the acute attack to subside in order that the removal of the 
appendix may be effected in the interval period when the dan- 
ger of operation is reduced to a minimum. The surgeon 
should always bear in mind that this second plan of treatment 
carries with it important complications, in that every attack 
increases the number of adhesions, by the extent and charac- 
ter of which the difficulties of interval operations may be 
measured. In the fulminating variety of appendicitis delay is 
especially dangerous. Even with the promptest action failure 
may obtain on account of the rapidity and extent of infection, 
and the almost unaccountable, extensive lesions of the parts 
affected, such as gangrene with perforation of the appendix. 
In recurrent and chronic appendicitis operation should be 
advised as a safe treatment, not only because the disease in 
many instances incapacitate its victims, but because it is a 
constant menace to life. When suppuration is present opera- 
tion should be done without delay. The great difficulty of 
deciding upon this important phase of the disease is the 
obscurity of symptoms which indicate the presence of pus. 
It must not be forgotten that the pulse rate is an impor- 
tant guide towards determing operative influence. Whenever, 
after the first twenty-four hours of the disease, the pulse 
gradually increases to no or 120, whether the temperature is 
high, normal or subnormal, it is dangerous to delay operative 
treatment. The patient's general condition should be care- 
fully observed. If after a short time he looks ill the opera- 
tion should be discussed. This state cannot be described in 
words. The whole attitude of the patient, together with 
facial expression, color of skin must be taken into consider- 
ation. 
Perforation is indicated in the late stages of severe types of 
appendicitis by the loss of the area of hepatic dullness due to 
the presence of free gas in the peritoneal cavity, a sign that 
is infallible. When this sign, together with a fecal odor of 
breath is present, operation should be resorted to at the ear- 
liest possible moment.