rule "that he who opens an abdominal cavity must be prepared to meet any or all the complications which may arise in this most complex portion of the human anatomy."

The first and most important point is the necessity for an early diagnosis, because the good results for operation in appendicitis depend upon the time of operation. The danger increases in direct ratio with the progress of an attack.

In women who are liable to become pregnant and who have had an attack or attacks of appendicitis, the appendix should be taken out in order that the dangerous complication of pregnancy and appendicitis may be avoided.

This is particularly true if an attack of appendicitis supervenes upon pregnancy. The latter condition does not contraindicate operation under the circumstances, but rather, on the other hand, makes operation more imperative.

Another point is one based upon a rich personal experience, covering both operative and non-operative cases. It is that the number of cases of appendicitis that become perfectly well, cases that do not suffer during the interval between attacks, and that are not subject to the certainty of future attacks, are so extremely rare that the question of curative treatment resolves itself to the time of operation.

FIFTY-TWO CASES ILLUSTRATING MY PERSONAL EXPERIENCE WITH THE MEDICAL AND SURGICAL TREATMENT OF APPENDICITIS.

BY GEORGE S. PECK, M.D.,

YOUNGSTOWN.

ALTHOUGH there has been already much written and said upon the subject of appendicitis, it should still remain open and be most freely and thoroughly discussed. My apology for reporting the following cases is that I believe it is the duty of every physician to report his cases (unsuccessful as well as successful), in order that individual experience may give correct statistics. While it has been well established that appendicitis is one of the most important as well as one of the most treacherous diseases the physician has to encounter, and it is also undisputed that it is the cause of more deaths than any other acute abdominal disease, yet a fact still to be emphasized is the cry of inflammation of the bowels, which part of the profession seem so slow to recognize as appendicitis. The diagnosis should not be difficult. There are four cardinal symptoms which, if occurring in the order given below, will almost invariably insure a correct diagnosis: first, sudden severe pain in the abdomen, generally of a colicky nature, located in any part or extending over the entire abdomen; second, always nausea and frequently vomiting; third, increased temperature; and fourth, localized tenderness in the right iliac region. Some patients will have diarrhea; others may be constipated. And it is not essential to find a large mass or rigidity of the rectus muscle in order to confirm the diagnosis. In my own experience I have never failed to make a correct diagnosis when the four cardinal symptoms were present.

That an early operation is to be advised goes without saying. Surgeons differ in the methods of operating. Some advise, in the acute suppurative form, simple incision and evacuation of pus. If

the appendix cannot be easily found, leave it, drain and pack; then in the interval between attacks remove the appendix, always providing one can get the consent of the patient, which I have found to be extremely difficult. A few surgeons advise the liberating of all adhesions and the removal of the appendix in all cases of acute suppurative appendicitis, and they report good results. We all know that each case is a law unto itself, and yet I believe it is the duty of every surgeon to make a complete operation in the vast majority of cases. We are certainly called to patients at the eleventh hour where it is necessary to do a life-saving operation, but they are becoming more and more rare, and I believe the time is not far distant when all surgeons will advise the breaking up of all adhesions, the removal of every diseased appendix, and the closing of the incision, as we do now in the operation for pyosalpinx as advised by Morris, Price, and McMurtry. In my last three cases I have followed that method, and the results have been far beyond my expectations. In each case pus was evacuated, the cavity cleansed with hydrogen peroxide and distilled water, and the entire abdominal cavity throughly flushed, a glass drainagetube placed down to the stump, and the incision closed. Two of the cases were discharged in three and one in four weeks.

CASE I.-E. W., aged six years, male; residence, Youngstown, Ohio. Was taken sick May 19, 1891; sudden severe pain, nausea and vomiting, increased temperature, and localized tender mass in right iliac region; medical treatment for eight days. Operation May 27, 1891 lateral incision; about a teacupful of thick pus evacuated; appendix not removed; irrigation, drainage, and gauze packing; discharged. Recovered in five weeks.

CASE II.-J. G., male, aged seventeen years, clerk in a grocery store; residence, Youngstown, Ohio. After lifting a barrel of sugar, October 7, 1892, he complained of sudden severe pain in the abdomen, nausea and vomiting, increased temperature, and localized tenderness in the right iliac region. Was treated for typhoid fever until October 24th, when I was asked to see him in consultation. Patient was lying in bed with both knees flexed, abdomen very tympanitic; temperature 102°; pulse 100, with a well-defined tender mass in the right iliac region. Operation advised and urged; consent withheld until October 27th: lateral incision; about a pint of fecal-smelling pus evacuated; appendix not removed; cavity

irrigated, drained, and packed with gauze; temperature and pulse dropped to normal. Fecal fistula on third day. The eleventh day after operation complained of pain in the left iliac region. Continued to grow worse until the sixteenth day, when, with the abdomen very much distended, temperature 103°, pulse 180, I opened the abdomen with a median incision and evacuated about a quart of sero-purulent fluid; abdominal cavity thoroughly irrigated, drained, and packed. Reacted well, and did nicely until the twenty-second day. Death on the twenty-fourth day after the first operation.

CASE III.-F. M., aged thirty years, married, American; residence, Warren, Ohio. Patient of Dr. Sherwood. Sudden severe abdominal pain, nausea, increased temperature, and localized tenderness in right iliac region, February 1, 1893; medical treatment; was able to be out and attend to business February 15th. February 18th, severe chill, temperature 105°, pulse 120. Seen in consultation 9 A. M., February 19th; temperature normal, pulse 80, abdomen slightly distended, and there was a well-defined tender mass in the right iliac region. Operation 2 P.M., February 19th: lateral incision; about a teacupful of thick, fecal-smelling pus evacuated; appendix not removed; irrigated, drained, and packed with gauze. Fecal fistula on fourth day. Made a good recovery, with fistula closed, in six weeks.

CASE IV. Mrs. C. R, aged twenty-three years; residence, Girard, Ohio. Patient of Dr. Warren. Pregnant about six months. Was taken suddenly ill with symptoms of appendicitis April 8, 1893. Seen in consultation April 13th; severe pain, with a well-defined tender mass in right iliac region; temperature 102°; pulse 116. Operation 4 P.M., April 14th: lateral incision; no pus; an enlarged, inflamed appendix removed; incision closed with silkworm-gut; premature labor on tenth day after operation; good recovery.

CASE V.-S. McC., aged forty years, married, occupation puddler; residence, city. June 23, 1893, sudden severe pain over entire abdomen, nausea, vomiting, increased temperature, and localized tenderness in right iliac region. I was called June 27th. He was suffering pain; right rectus muscle very rigid; temperature 100°; pulse 80, and a very tender mass in the right iliac region; medical treatment. At 10 A.M., June 29th, patient seemed much

better; temperature 99°; pulse 60; 11.30, severe chill, lasting over one hour; severe pain over entire abdomen; abdomen tympanitic and tender upon pressure; expression anxious; temperature 102°; pulse 100; removed to City Hospital. Operation at 2 P.M., June 29th: lateral incision; fecal-smelling pus evacuated; appendix not removed; irrigation, drainage, and gauze packing. Recovery uneventful.

I

CASE VI.-W. B., aged twenty-six years, male, married, steelworker; residence, Brier Hill, Ohio. Patient of Dr. H. E. Blott. Was taken sick at 3 A.M., December 8, 1893. Sudden severe pain in region of umbilicus, nausea, vomiting, increased temperature, and localized tenderness in right iliac region; saline treatment. was asked to see him in consultation at 9 A.M., December 9th. Abdomen tympanitic, with rigidity of right rectus muscle, and exquisite tenderness in right iliac region; temperature 101°; pulse 100. Continued saline treatment. Operation at City Hospital, December 14th: oblique incision over most prominent part of mass; about four ounces of pus evacuated; appendix not removed; irrigation, drainage, and gauze packing. Pneumonia in right lung on sixth day. The incision was reopened twice, and from two to four drachms of pus evacuated each time. Recovery slow but good. Was in the hospital sixty-three days. Ventral hernia one year later. CASE VII.-B. C., aged twenty-four years, male, single, laborer; residence, Niles, Ohio. Patient of Dr. A. J. Leitch. December 1, 1893, usual symptoms of appendicitis. Medical treatment until December 21st, when I saw him in consultation. A large, fluctuating mass in right iliac region, extending almost to the umbilicus; temperature 102°; pulse 100. Operation 4 P.M., December 21st incision over the most prominent part of mass; about three pints of pus evacuated; appendix not removed; irrigation, drainage, and gauze packing. Recovery uninterrupted.

CASE VIII.-L. H., aged twenty-six years, female, single; residence, Warren, Ohio. Patient of Dr. Sabin. Operation during interval between attacks, three months after first attack. Operation 10 A. M., July 26, 1894, at Youngstown City Hospital: incision over cecum; appendix, buried in mass of dense adhesions, was removed; incision closed with silkworm-gut. Patient did well

1 Cases VIII., IX., X., XI., and XII. were reported in full at the Toronto meeting, 1894, and inthe Annals of Gynecology and Pediatrics.