In consideration of the facts that the course of appendicitis can never be accurately foretold, and that the dangers resulting from delay in operation are many and severe, the following outline of treatment is justified from our present knowledge of this disease: Upon the appear ance of severe pain in the abdomen, with the maximum intensity over the region of the ap pendix, nausea, or vomiting, and a point of tenderness in the right iliac fossa, the patient should be placed at rest, all food withheld and the family physician sent for. When the at tending physician has made the diagnosis of appendicitis there is no treatment to be dis cussed save operative interference. Whether the operation should be performed immediately will depend upon the extent of peritoneal in volvement, but this question should be decided by the surgeon called into consultation and in whose hands the management of the case belongs. In fatal cases which have been fol lowed by a reopening of the wound, a study of the conditions is of great interest. When death has taken place from a rapid septic poisoning or toxemia the abdomen may show nothing except some thin cloudy fluid in the pelvis and congestion of the petitoneum covering the intestines, giving them a gscaldedo appearance. In the abscess cases the right iliac fossa is found filled with a green purulent ex udate adhering closely to the groin and the in testines. There may be small quantities of pus which have formed since the operation. If death does not occur for several days after operation, and nature fails to check the spread of the disease, this purulent exudate may reach from the liver to the pelvis with infection of the portal vein, the liver and the lymphatics behind the peritoneum. With extensive leak age, the entire peritoneal cavity may be filled with greenish pus.
There are many more cases of minor mani festations of appendiceal inflammation than of the acute disease. Both clinical and mi croscopical evidence proves that it is a great exception for an adult to have escaped some slight disease of the appendix. That it is
possible to have a chronically diseased ap pendix, or occasionally even a high grade of acute inflammation of that organ, without symptoms is now definitely known; on the other hand, such conditions often produce symptoms which are so slight or non-character istic that their origin or significance is entirely overlooked. The more typical cases of chronic give rise to symptoms referable to the location of the appendix itself, that is, dis comfort, distress of some sort or actual pain in the right lower quadrant of the abdomen. Occasionally, by reason of an abnormal situation of the appendix, the symptoms and signs may be either higher or lower than usual, or even, as occasionally happens, on the left side. Most curious and difficult of interpretation are the so-called referred symptoms. Through the medium of the nervous system and the inter dependence of different portions of the gastro intestinal tract, chronic irritation of the ap pendix may manifest itself by symptoms point ing to disease of an entirely different portion of the tract, most often the stomach and the duodenum. The function of the large intestine also may be disturbed, suggesting disease of that organ, whereas the primary source is to i be found in the appendix. This so-called ap pendiceal dyspepsia is by no means uncommon and usually goes unrecognized until an attack definitely incriminating the appendix occurs. It is not far from the truth to say that appen dicitis is the most common cause of dyspepsia. The only treatment of avail in such cases is removal of the offending organ, a procedure which often remedies diverse dyspeptic con ditions in a most remarkable manner. Consult Brewer, G. E., Textbook of (New York 1915) ; Deaver, J. B., 'Appendicitis: Its Diagnosis and Treatment> (1913) ; Kelly, H. A., (Vermiform Appendix and Its Diseases (1910).