Forty-five cases of appendicitis com plicating pregnancy, diagnosis being con firmed in thirty by operation or post mortem. It is concluded that: 1. Ap pendicitis may attack a pregnant woman at the beginning or at any time during pregnancy in the puerperium. 2. In most cases it causes abortion. The child dies, as a rule, very rapidly from infection. 3. It is only possible to save both mother and child when the abscess is limited and encysted. 4. Every type of appendicitis may occur. 5. The diagnosis may be difficult, owing to the enlarged uterus, or still more so during the puerperium, but is usually possible with care. 6. Treatment consists in operating as early as possible. A preliminary induction of premature labor is unjustifiable. since pregnancy is not always interrupted if the mother recovers. 7. Prophylaxis con sists in operating in every case of re lapsing appendicitis in a young girl or non-pregnant woman during the period of sexual activity. Pinard (La Sem. Mad., Mar. 23, '9S).
Prognosis. — The chances that a first or second attack of acute catarrhal ap pendicitis will be renewed are about 77 per cent.; but, when a fourth or a fifth attack has occurred, the probability is very great that more will follow and ultimately end fatally, unless operation is performed.
After the patient has gone through an acute attack safely, and the characteristic tumor indicating an acute suppurative process is felt, a circumscribed perito nitis, rather than a general suppurative one, is likely to occur if another attack takes place.
Analysis of 50 cases of recurrent ap pendicitis operated. Thirty-nine were males and 11 were females. Twenty three occurred in persons between 20 and 30 years of age. The youngest patient was 10 and the oldest 53 years of age. In only 5 patients had there been but one distinct attack. In almost every case the lumen of the appendix was either partially or completely oc cluded at some point in its course. In 6 cases concretions were present, but in no instance was any foreign body found. All recovered. Southam (Brit. Med. Jour., Jan. 10, 1903).
Surgical Treatment. — This is indi cated when the relapses are frequent and increasing in severity, and when a tumor is present during the interval, the pres ence of septic accumulation, ulceration. or perforation being likely. It should be performed during a period of quiescence in the manner described in the preceding pages.
In relapsing eases the operation should be performed between the attacks. Roux (Revue Mad. de la Suisse Rom.. Sept.,
Oct., Nov., '91; Jan., '92).
The general consensus of opinion favors operation, both in latent eases with re lapse and those which are accompanied by a general purulent peritonitis. Heelus (La Semaine EIed., June 22, '02).
Prompt surgical interference during the interval between the attacks is an advisable and safe procedure. The phys ical characteristics define clearly the situation of the appendix. Bryant (Jour. Amer. Med. Assoc., Nov. 3, '94).
Fifty-one cases of recurrent appendi citis operated during intervals between attacks, with but one death. Conserva tism should be observed, however, about operating during an acute attack. There is no distinction between simple appen dicitis and appendicitis with perforation, as far as operative indications go. Kum mel (Le Bull. Med., Oct. 6, '95).
Four cases of chronic appendicitis, in each of which operation was clearly in dicated and had been advised by several eminent surgeons, successfully treated by "tonic" doses of protiodide of mercury. Horwitz (Annals of Surg., Jan., '98).
The most suitable time for operation is about three weeks after the commence ment of the attack, when all acute symp toms have disappeared and the tempera ture and pulse have become normal. G. Barling (Brit. Med. Jour., Jan. 29, '98).
Conclusions are that in all cases of appendicitis during the first attack, oper ation should not be performed unless sup puration or diffuse peritonitis requires it. In lapsing or recurrent cases, in which it is probable that distortion or other per- I manent injury to the appendix exists, one should operate. E. D. Ferguson (N. Y. Med. Jour., Mar. 26, 'OS).
According to Czerny, the first acute attack of appendicitis belongs to the physician. This attack may: (ft) pass by without complication, in which case there is no occasion for surgical inter ference; or (b) earlier or later, with alarming symptoms of general or local nature (fever, rapid pulse, pain, dullness on percussion, rigidity), it may go on to perforation and abscess-fo•mation. Such an abscess either (A) leads to progressive and threatening general peritonitis or (B) it remains circumscribed and be- , comes encapsulated, the first severe symptoms continuing without important change. The conditions (b), (A ), and (B) indicate surgical treatment, as do all chronic recurrent forms of appendicitis, whether they be purely catarrhal, ulcer ative, perforating, or obliterative. Edi torial (Phila. Med. Jour., July 9, TS).