In a series of 517 cases the mortality was 23.S per cent. in those of the cases treated in pre-operative days. Of the 517 cases, 389 were operated on and 12S treated without operation. In the latter the mortality was 3.12. Of 319, Si were interval cases, in which there was 1 death. Of 305 operated on in the acute stage, OS died. The great point in treat ment is to anticipate the severer forms resulting in septic peritonitis by early surgical interference. Palle to advise operation at the end of twenty-four hours or thirty-six hours, if the patient is not improving. G. E. Armstrong (Lancet, Sept. 18, '97).
When a case of diseased appendix is personally seen operation is advised; if this is not assented to. all responsibility in the case is disavowed.
Early operation is admitted by all to be the proper course in the acute perforating peritonitis eases. In ab scess cases it means small abscess easily and safely dealt with. In non-perfo•at ing cases it means avoiding all sorts of catastrophies to the patient, such as perforation, gangrene of the organ reaching the surface and infecting the peritoneal cavity, recurrence of the dis ease at a possible inopportune time, and last, but not least, cure of his dis ease. J. C. Davie (Dominion Med. Monthly, Nov., 1901).
Surgical Treatment.—Operation is in dicated:— 1. When severe symptoms come on suddenly, either at the onset or during the course of the disease.
2. When in a mild case the symptoms are gradually increasing in intensity up to the third day.
3. by the third day, a firm, gradually growing mass can be felt at the seat of localized pain, and especially if there is localized oedema.
4. When abdominal distension, high pulse, diffusion of pain, and other evi dences of general peritonitis conic on at any time in the course of the disease.
By the second day, certainly by the third and a fortirrri later, the operation should be done if the following indica tions are present: (1) if there is ab dominal pain, most marked in the right iliac fossa, and especially with tender ness at McBurncy's point, attended pos sibly with nausea and vomiting; (2) if there is rigidity of the right abdominal wall; (3) if there is fever up to 100° F., 101° F., or 102° F., which does not yield to medical treatment; (4) if by minute and careful palpation tumefaction and increased resistance can be discovered with possible dullness and, rarely, fluctu ation; and (5) if there is oedema of the abdominal wall. W. W. Keen (Annals of Surgery, Apr., '91).
Experience of one hundred and eighty one cases. Operation is called for imme diately in a sudden severe attack of ap pendicitis with pain, vomiting, more or less distension, and high pulse, with localized tenderness. In such a ease the appendix is usually perforated and the bacteria are very virulent. Richardson
(Amer. Jour. Med. Sciences, Jan., '94).
In entire personal experience not a death seen which could not properly be ascribed to delay in timely and skillful surgical interference. Every case from the very beginning should be treated by a surgeon, with a medical attendant. Wyeth (N. Y. Med. Jour., June 30, '94).
That some patients get comparatively well without operation no one denies, but usually improvement commences in such eases within from twelve to six teen hours from the onset. On the con trary, if the symptoms become aggra vated after this time or if the disease persists in spite of palliative measures (opium excluded), it becomes an opera tive case, and the physician or surgeon who hesitates to advise operation robs his patient of one of the best means known to science at the present day of saving life in this dreaded disease. J. C. Kennedy (Med. Record, Nov. 14, '96).
Estimate of the number of appendiceal patients who die under medical treat ment, based on 100 consecutive personal operative cases. In that particular series the death would have been about 28 per cent. eventually.
Estimnted One Hundred Consecutive Operative Deaths Appendicent Cnses. :Medical Treatment.
7 cases of tuberculosis and can cer 5 I ease of strangulation of bowels by appendix adhesion band 1 33 abscess cases 15 8 cases with hard, incarcerated concretions 2 12 cases of occluding stricture dams 5 34 cases in common interval stages or in acute stages before ad vent of pus 0 The surgical death-rate in this series of 100 cases was 2 per cent. R. T. Morris (Med. Record, Dec. 26, '96).
I. A frequent or progressively accel erated pulse-rate of itself a prime indi cation for operation. 2. Pain localized and progressive is a valuable associated condition. When pain is sudden, severe, and progressive, and accompanied with chill, it means perforation or abscess, rupture, and operation. 3. Increase of temperature is third in importance, but when associated with one or more of the previous symptoms, and more especially with increase of pulse-rate, it makes immediate operation a foregone conclu sion. 4. The gradual subsidence of the three cardinal symptoms — pulse-rate, pain, and temperature—is a legitimate reason for postponing immediate opera tive interference. 5. In cases of abscess it is generally safer, while watching for urgent indications, to wait until adhe sions have formed a sufficiently pro tective wall. 6. In eases of recovery after mild attacks and without opera tion we are never sure of recurrence until the latter takes place, when the operation can be done soon enough, and, all other circumstances being equal, pref erably in the interval of a succeeding attack, when the tissues are not in an inflamed condition. G. F. Shrady (Med. Record, Jan. 9, '97).