“In many of the ordinary surgical operations it is not necessary to follow out the details with any great degree of accuracy, because failure to do this will at most result in confining the patient to bed a little longer than usual or necessary, while in the appendicitis operation it is likely to result in the death of the patient.

“This position, when taken in the discussion of appendicitis in medical societies, has frequently given rise to severe criticism because upon its face it looks as though appendicitis operations should be performed only by the few who happen to have acquired especial skill in this class of surgery, possibly at the expense of the lives of a number of patients.

“This, however, is not the case.  The operation is simple enough if one will but take the pains to learn it, and every town of five thousand inhabitants should have at least one man perfectly competent to do such work.  But if there is no such man available then I would say most emphatically that the patient’s chances of recovery are many times greater with proper non-surgical treatment than with an operation.  Of course, patients have occasionally recovered, by accident, in the hands of most incompetent surgeons, but the death rate after appendicitis operations in the hands of incompetent surgeons is absolutely frightful.

“My experience and personal observation have taught me that physicians and surgeons, as a rule, are absolutely conscientious, and that when they perform this operation, notwithstanding the fact that they themselves know they are incompetent (and they alone must necessarily be their own judges as to their competency), they do it because they have been taught that this is the only right treatment, and that the patient is entitled to an effort on the part of the physician or surgeon to save the life which is in danger.  I believe that this is extremely bad teaching, and that many hundreds of lives have been sacrificed unnecessarily on account of this.  I say this because I am confident that with proper non-operative treatment almost all of the cases which are diagnosed reasonably early may be carried through any acute attack, no matter what its character may be.

“I would then say, primarily, that no case of appendicitis should be operated upon unless a competent surgeon is available.  This, of course, does not apply to cases in which a circumscribed abscess has formed which anyone can open with safety provided he has sufficiently good judgment not to do anything further.”

Here I must differ.  If the case has not been complicated by overmuch handling, digging, punching, thumping and otherwise manipulating in the name of bimanual diagnosis, no one has any right to put a knife into the pus sac for it matters not how well it is done the drainage is bad and is in opposition to the natural outlet through the bowels.  Of course if the unfortunate patient has fallen into the hands of some one who believes it the prerogative of a physician to manipulate in season and out of season, and who has converted a typhlitic abscess into a perityphlitic one, or forced the pus to burrow towards the groin, then a free opening with a let-alone after treatment, except thorough drainage, may be followed in time by restoration to health; however, if the patient fully recovers it will be more from luck than from the usual management.