his life. The rule applies with greater force in cases with unmistakable symptoms of appendicitis. For instance, you see a patient with a sudden attack of pain in the abdomen, with nausea and vomiting, with local • tenderness accentuated over the region of the appendix, with perhaps a rise of temperature and an accelerated pulse; the conclusion is that you have an inflammation of the appendix. An immediate operation is indicated, and it is the duty of the attending physician to so state to the family, and a surgeon should be called in at once. It is useless and dangerous to delay this matter; operation is imperative, and the sooner done the better. It may be urged that many cases get well without operation, and that it would be well to wait. There is not a man living who can with any certainty differentiate the pathological conditions that exist inside the abdomen in a case of appendicitis. The mere opening of the abdominal cavity can be productive of but little harm, and if properly done will in nowise prejudice the case. If there has been a mistake in the diagnosis, the cavity can be closed; if the diagnosis is correct the appendix can be removed, or treated otherwise, as the surgeon may elect, and perhaps the life of your patient saved. Nine times in ten there will be no mistake in the diagnosis, and I repeat that, in a case with symptoms such as I have given, it is an imperative duty that an operation be done. Nay, more: I would state that in a case with symptoms much more obscure, such a one as I am now going to report, it is the duty of the surgeon to operate at once. And I may state that this opinion has been largely strengthened since assisting in the treatment of the case mentioned. I shall first give the history of the case as furnished by Dr. W. A. Quinn, the attending physician, previous to the time the patient was seen by me. It is as follows:

R. D., aged eighteen; occupation, weighing clerk. On the afternoon or evening of January 11th felt a little pain in the abdomen, and on Saturday, about the middle of the afternoon, the pain had become so severe that he rode in a buggy from his place of business to his home.

Sunday morning at eight o'clock I was called to see him, and found him with what then seemed to be an intestinal colic. His temperature was only slightly elevated (100.5°); his circulation was not at all disturbed, pulse 78; skin presented a perfectly normal appearance; tongue was coated and the bowels were costive. He complained of colicy or griping pains, and tenderness on pressure over the entire abdomen; some loss of appetite but no nausea. He had had no hot flushes nor chilly sensation; no sweats.

I carefully examined his belly; and percussion over its entire area revealed only the normal resonance, and palpation furnished no evidence of a tumor or induration. A hypodermic of morphia was administered, and three powders of calomel and bismuth ordered taken at intervals of four hours, to be followed by a full dose of Epsom salts.

In the evening at eight o'clock patient felt more comfortable; pulse 78; temperature 99.25°, and in very little pain; in fact he thought so lightly of his little indisposition that he expected to be able to resume his work Monday morning. On Monday morning patient stated that he had slept fairly well, his bowels had moved out freely and nicely, and he was feeling pretty comfortable. The pain on pressure was less marked than it had been before, but was now a little more pronounced centrally, just below the umbilicus and in the left iliac region. No flatness nor induration or other evidence of a tumor could be made out. Temperature 99°; pulse 76; had some appetite. Ordered five-grain doses of quinine at intervals of three or four hours. At eight o'clock in the evening the pulse, temperature, and condition unchanged.

On Tuesday morning, the 15th, patient expressed himself as having passed a good night, and feeling comfortable. Pulse 76; temperature 98.5°; still slight pains at intervals, with the tenderness over the abdomen slightly marked in the left iliac region, and less so centrally just below the umbilicus. A close inspection of the skin gave no clew to the trouble within, and palpation and percussion did not yet furnish evidence of the character of the trouble. Nourishment was ordered, and very little else given during the day. In the evening the pulse was 78; temperature 99.5°; tympanitis a little more marked; condition. otherwise unchanged.

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I first saw this case on the 16th of January (Wednesday) in consultation with Dr. Quinn. Examination revealed very slight tenderness on deep pressure in the cecal region; more pronounced tenderness with slight dullness on percussion over the sigmoid flexure. Slight tympanitis over remaining abdominal region; tongue coated, brownish with red edges; temperature 99°; pulse 78. Diagnosis, local peritonitis, probably from appendicitis. Calomel, grains v, was ordered to be followed by salines; turpentine stupes over abdomen; morphia if necessary to control pain.

On the morning of the 17th (Thursday) the patient felt better; countenance bright, but general condition about the same; bowels had moved well; pulse 78; temperature 99°; tongue coated. During this

day there was tenesmus with several stools dysenteric in character. Some induration with slight dullness over region of sigmoid flexure. No rigors. Opiates were given to control pain of tenesmus and check bowels.

On Friday, the 18th, there was slight increase of dullness over sigmoid region, induration more pronounced; patient had slept fairly well, and had taken nourishment frequently. Tincture of iodine and belladonna, equal parts, was painted over the induration, and turpentine stupes were ordered over entire abdomen. Quinine, which had been prescribed before, was kept up.

On Saturday patient was not so well; had a rather restless night; pulse still 78; temperature 99.5°; had tenesmus during the night with several copious stools; slight increase in area of dullness over sigmoid region, which now extended to median line. Tongue red on edges, dry, with brownish coating in center. Dr. W. M. Hanna was called in. The indications pointed to the formation of a pus sac (extraperitoneal), and it was agreed to aspirate on the following morning, and if pus was found to cut down and evacuate the abscess. A hypodermic needle was inserted with negative result.

On Sunday morning (the 20th) there had been a perceptible increase in the area and prominence of the tumor in left iliac region; pulse was still 78, and temperature 99.5°. Patient had passed a bad night. Aspirator needle was inserted, but only a slight quantity of serum was withdrawn. The needle was again inserted nearer the site of the first point of induration; result, a few drops of serum with decided fecal odor. After consultation further operative measures were postponed.

Patient passed a restless day and night, and on Monday morning, the 21st, he was found in the following condition: Pulse 122; temperature 102°; countenance haggard; pain over entire left side accentuated over the ninth and tenth ribs, in axillary line. Tympanitis was general and there was snow-ball crepitation, emphysematous at the point of the most intense pain. Perforation had taken place and operation was considered as the only hope. Dr. Hanna was not present at the time, but saw patient shortly afterward and fully concurred. At the request of the family Dr. Edwin Walker, of Evansville, Indiana, was present and assisted in the operation.

Operation was begun at 2:30 P. M. After opening the abdomen the intestines were found bound together by adhesions showing general peritonitis; in breaking up intestinal adhesions a pus cavity was ruptured

far over in the iliac region, almost immediately over the sigmoid flexure.

The sac was adherent to the abdominal wall and to the intestines, and from the rupture, pus, fetid in character, welled out into the abdominal cavity. After emptying the pus cavity and flushing out the abdomen, further examination revealed a small stream of pus which came from an additional pus sac which probably communicated with the first by a very narrow opening, or it may have been adherent to the first, and in breaking down the adhesions an opening may have been made into it. I am of the opinion that there was a communication between the two, as the walls of the second sac were thick and strong; however, the opening in the second was enlarged, and an enormous quantity of fetid pus was evacuated.

This sac extended from the left iliac region downward under the intestines through the folds of the mesentery to the cecum. The appendix was not found, nor was it particularly sought for. After thoroughly flushing out the sac and the abdominal cavity with hot sterilized water, a roll of iodoform gauze was passed entirely through the sac and through a counter-opening in the abdominal wall in the right iliac region. The abdomen was then closed and the patient put to bed with a pulse of 140, temperature 103.5°. Under the use of stimulants and the application of hot-water bags the body warmed up and slight reaction took place, but the pulse never came below 140, and the temperature gradually increased until it reached 107.5°. Patient was restless, but there was little if any pain after the operation. He grew weaker and weaker, and died at 1 o'clock A. M.

Taking this case as stated, with its obscure symptoms and slight constitutional disturbance, the question arises, When should operation have been done? Undoubtedly when the case was first seen by me, or before, though at that time I did not think so, but now I do not hesitate to say that, given a case such as I have described, with obscure symptoms, with slight disturbance of pulse or temperature, with tenderness over the abdomen, with no tumor or special pain over the region of the appendix, but which does not yield immediately to ordinary treatment, then I say an exploratory operation should be done. If there is trouble it can be righted, if there is no trouble very little harm has been done, and you have the satisfaction of knowing that you have done. your duty.

Murphy Journal of the American Medical Association, March 1995, in reply to the question. When should we operate? says: As we are unable from the signs and symptoms to determine the exact pathological condition, are we justified in allowing the probability of fatal conditions to continue for such a period of time without such action as would place the patient beyond the possibility of resene, even by operative procedure? No, not until such time as the physician is able to determine the exact pathologic condition and danger in the individual cave, and indeed we must now consider that time far distant; he is not justifed at the peril of the patient's life in restraining the surgeon from acting. It must be conceded by all that an operative procedure in competent hands is in itself one involving very little risk, while the continuation of the pathologic processes in many cases greatly jeopardizes the life of the patient.

There is only one safe position to take, and that is, in every case in which a diagnosis of appendicitis is made the operation should be immediately performed. It is true that many cases can recover without operation, but we can not differentiate in the early stages which cases are going to be favorable ones. It is further true that the earlier the operation is performed the less danger to the patient, and the greater ease of removing the appendix. In a majority of cases, if an operation be performed within forty-eight hours after the onset of the symptoms, the appendix is not yet ruptured, and can be removed without pus infection of the peritoneum, an advantage of which even the boldest surgeon is pleased to avail himself. In the later stage, if the surgeon is unfortunate enough to be called at the time that the peritoneum is flooded with pus and the patient collapsed, it is his duty to perform the operation and give the patient the advantage of the small percentage in his favor in this forlorn condition. The rule first, last, and always should be, operate in every case of appendicitis, promising or unpromising, at the earliest possible moment.

HENDERSON, KY.