TILE SLTIWICAL TREATMENT OF APPENDICITIS The mode of treat merit of this disease seems to he definitely settled.
Indications for Operation.--Early operation offers the best chances, and even those physicians who were hesitating with the use of the knife and preferred expectant treatment—i.e., internal therapy—as long as possible have now come to advise the early operation. The author has treated one hundred eases of appendicitis in children and based on these he is convinced that Riedel is right when he urges the necessity of an early operation.
[This and the following paragraphs will seem unnecessary am I rather amusing to the American physician. While our German Con were wrangling in their discussions about the right time for the operation and were wasting their time over this and losing their patients as well, we in the United States were firm believers in operating as soon as the diag nosis was made and had the best of results.—THE TRANSLATOR.] The results of operations aro just as good in children as in adults, as long as they are operated early enough.
Children, especially small ones, are very susceptible to infection from the appendix (Kirmisson, Xeuherg). The threatening spectre of general peritonitis more frequently catches the child than the adult; true, the disease is rarer in infancy than later on (we have only observed one case in a child under two years of age).
If we should adhere to expectant treatment we take upon ourselves a heavy responsibility. The consensus of opinion is now, considering all the symptoms, that we cannot draw any conclusions as to the true state of the pathologic-anatomic. conditions. We are taking greater chances by waiting than by operating, as long as we only proceed as conservatively as we are being taught to do by the most modern surgery. In the last two years we have not lost a single child which had been oper ated within twenty-four hours, and these included cases which showed decided cloudiness of the exudate and formation of pus around the per forated appendix which was not walled off and in the pus of which we were able to show streptococci.
The frequent question when to operate, should be changed into when can we afford to wait? Sonnenburg has taught us in his last publi cations a most admirable rule which we have employed for the last year with the best of results.
The treatment would be as follows: Every ease of appendicitis should he sent to the surgical ward or a private room in a hospital as soon as the diagnosis is made. We can only adopt a conservatively expectant treatment without assuming grave responsibilities when we keep the knife near at hand. Only under these conditions can we afford to wait in simple appendicitis, though the diagnosis of this is by no means easy and we may frequently make grave mistakes. The fever usually does not exceed 37.5° (99° F.), the pulse is not above 90 nor the leuco cytosis above 15,000. In such a case we have to deal, according to Son uenburg, with an exudation into the appendix, which could not be discharged owing to valvular closure, cicatricial contraction from an old and overlooked chronic process or through biologic involution. In these cases a light laxative, one or two tablespoonfuls of castor oil, may cause increased peristalsis and removal of the exudate.
Should this not have the desired effect, or the leucocyte count, pulse, and temperature rise (3S° (101° F.) (100 : 20,000), and we find a large number of young leucocytes, then we were either mistaken in our diagnosis or the process is progressive and our only salvation lies in the knife; even if the process should regress we are by no means sure that we have not made a mistake in diagnosis.
A boy of eight years was sent to our ward with a diagnosis of appen dicitis in the first stage. Owing to the symptoms we have just given we considered this to be a case of appendicitis simplex and treated the child with castor oil. The symptoms decreased and the child was dis missed at the end of a week. After six months he returned with a second attack and was operated on, and we found the site of an old perforation, a sear, which surely dated from the former sickness. From this we saw that at that time we had not to deal with a slight sickness and that we had then been misled by the symptoms.