In appendicitis complicating pregnancy early operation on all but the very mildest eases recommended. 1. Within twelve hours in acute perforative cases. 2. A rapid pulse (116 to 120) is a strong indication for operation. 3. if doubt exists, operation. 4. If, after a sudden lull in symptoms, recurrence manifests itself, operation. 5. In recurrent at tacks, during pregnancy, even if mild, operation indicated, especially in the early months of gestation. This re moves the possibility of a future attack in the later months, when the procedure is more difficult. Abrahams (Amer. Jour. Obst., Feb., '97).
Views of a large number of represen tative surgeons on chief indications for operation: I. Operation during the first twenty-four hours gives a mortality of I to 2 per cent., but GO per cent. of these operations are unnecessary. 2. Opera tion only in very severe cases and for supplication gives a mortality of 17 to 25 per cent. 3. Operation between these extremes gives a mortality of 14 per cent. Frederick Winnett (Canadian Practitioner, Mar., '97).
As soon as appendicitis is diagnosed, no matter how mild the case may be, an immediate operation should be per formed, unless a patient is in severe shock following sudden perforation. In such eases the shock should be first over come.
Series of Si eases, all acute with 1 ex ception, all suppurative or gangrenous, and 4 complicated with peritonitis in which appendicectomy was performed with perfect recovery with 1 exception. Operation favored in the acute stage and as soon as diagnosis is made. Twice the appendix was found on the left side of the body; the cases were consecutive suppurative or gangrenous appendicitis. In all but 1 the appendix was perforated. Bernays (Med. Record, Apr. 2, '98).
Two cases of appendicitis in pregnant women operated on. Both cases re covered and neither miscarried. One should not hesitate to operate during any period of pregnancy, or even during parturition, if the case requires it. Hun ter McGuire (Southern Med. Record; Canada Lancet, May, '93).
Case of successful operation for ap during the eighth month of pregnancy; dermoid cyst with a twisted pedicle also removed. Twelve hours after the operation labor-pains set in and the woman was normally delivered of a live child. At time of report, just fourteen days after the operation, both mother and child are alive and well. A. G. Ger ster (Annals of Surg., May, '93).
Operation advocated at the earliest possible opportunity in all those cases which have not shown definite signs of improvement within thirty-six hours. Suppuration occurs in a very much larger proportion of cases of inflamed ap pendix than is usually believed. In
many of these the abscess bursts sud denly into the bowel with instantaneous remission of all the symptoms; in others the pus gradually becomes inspissated and dried up. It is true that many of these cases recover without operation, but it is not good surgery to leave an abscess in close proximity to the general peritoneal cavity in the hope that it will not burst into it.
Another argument in favor of early operation is the very grave effect upon mortality which the postponement of the operation exerts in the case of those who, because of suppuration or of diffuse peri tonitis, come to operation at last. Fow ler, analyzing 127 cases, showed that 83 per cent. recovered of those patients who were operated upon in the first three days; GO per cent, of those operated upon on the fourth day; 5S per cent, of those operated upon on the fifth and sixth days; 50 per cent. of those operated upon on the seventh and eighth days; and only 33 per cent. of those operated upon on the ninth and tenth days. As Murphy has phrased it, one-half of all the patients who would have recovered by operation will die if we wait until the sixth day.
If in a case of inflamed appendix thirty-six hours have passed without definite improvement having shown itself, the responsibility for the consequences must, it seems, rest with those who recommend that an operation should not be performed. C. Mansell Moullin (Lan cet, Dec. 10, '99).
At first, after a mild attack, resort may be had to the regulation of the diet and to salines. Should the attack be repeated, or should the first attack be a severe one, the appendix should be removed. Opium or morphine should not be given during an attack; neither should an operation be performed during an attack unless (1) a chill should manifest itself; (2) the pain should be severe enough to require morphine; (3) the pulse is small, rapid, or irregular; (4) there is persistent vomiting; (5) there is persistent rigidity of the abdom inal wall; (6) an abscess can be felt; (7) the general condition makes it ha perative; (8) in doubt. Joseph Wiener, Jr. (Med. Record, May 19, 1900). Operation advised within the first twenty-four hours, since during that time it can be done with a maximum mortality of 2 per cent. The diagnosis can very readily be made within the first twenty-four hours. If the case is past the first seventy-two hours when first seen, it may sometimes be allowed to proceed without operation, if there is a circumscribed abscess with low tempera tune and no indication of great intoxica tion. J. B. Murphy (Chicago Med. Record, June, 1900).