societies and in the medical literature of this country. Physicians and surgeons have vied with each other in studying and in reporting cases, with a view to deciding the many disputed points in relation to the cause of the disease, the treatment and its results. The practitioners are few who have not been called upon to treat these cases, and who have not had reason to feel that much is still to be learned before a uniform standard of treatment will be attained. The last words has not been spoken or written; there are still mooted points to be settled; and for this reason the writer felt that he could not better occupy your time and attention than by briefly indicating some of the conditions and circumstances under which the general practitioner may very properly and wisely seek the advice, the support and the aid of the practical surgeon.

Much has been learned from the family physician in the past, and will continue to be in the future, in regard to the early symptoms, the course of the disease, the results of the so-called "expectant" treatment, and many other points. While from the very nature of things there can be no hard and fast custom in these matters, yet, as a rule, these patients require both medical and surgical treatment; so they should receive the services of the surgeon in addition to those of the physician. It goes without saying that many patients cannot command the services of an expert, but must rely upon the aid which is at hand. The heartiest co-operation should, and, I believe, does, exist between the physician and surgeon in the management, not only of this disease, but of all others in which the services of both may be required. The best interests of the patient, of the profession, and of the public, all lie in the same direction, and the more thorough and cordial is the understanding upon these matters, the better will be it for all concerned.

It is hardly necessary for me to say that I do not belong to the radical wing of the profession, which mainta ins that every case of appendicitis demands operative interference. The final and conclusive test of experience would seem to prove beyond a reasonable doubt the fallacy of that plan of treatment. According to Hawkins, of 264 cases of appendicitis, 190 ran their course without suppuration. Dr. Fitz thinks "that from twothirds to three-fourths of all cases are likely to recover from the

immediate attack without surgical treatment." Dr. M. H. Richardson says that of the cases to which he is called to decide the question of operation, about half recover without it. Dr. McBurney believes that considerable more than half of the patients will recover from the first attack without operation.

In 46 consecutive cases under the writer's care at the Boston City Hospital an operation was performed 24 times, with nine deaths. Of course, only the severest cases received radical treatment. The lighter cases, 22 in number, were treated "expec. tantly," and all recovered.

Now, unless a fairly large proportion of all these patients who recover without an operation are again seized with this disease in the near future, it will be difficult to convince any considerable number of our fellow practitioners, that every one of these patients should have been treated by abdominal section. Many individuals in our midst including several in our own profession, have been through one or more attacks of appendicitis in years. long gone by, and have to all appearances reached a safe and permanent recovery without an operation. It is difficult for the ordinary practitioner to understand why a radical operation should be universally resorted to in any affection, when about 50 per cent. of the victims will in all probability make a safe and permanent recovery without it.

As human nature is at present constituted, a large proportion of our patients will very likely prefer to run their chances of the future, rather than submit to an operation, not wholly devoid of danger, for a single attack of appendicitis which is neither severe nor prolonged. I am fully aware that occasionally an apparently mild case suddenly assumes an alarming and dangerous condition, but I question if this event occurs often enough to justify operation in every instance. At all events, the experience of the last ten years has not yet taught any such lesson to a majority of our best men, who have the most to do with this malady. What the future may have in store for us on this point remains to be seen.

The ground taken by the writer is, that patients with appendicitis, who are in collapse, or who are not sick enough to go to bed, or in whom the symptoms are mild and not prolonged, or, if severe at first, show a decided change for the better within

forty-eight hours, do not require an immediate operation. The larger proportion of these cases coming between these extremes may or may not require surgical interference, according to circumstances. It is for us to study each case carefully by all the light we can get, and try to decide judiciously as to which cases require operative treatment, and which can be safely carried through without it.

As a preliminary to our subject, a few words upon the diag nosis of appendicitis may be permitted. It is pretty well settled in the minds of the profession that peritonitis in the male means appendicitis, whatever may be the pecularity of the symptoms. The exceptions to this rule are so uncommon that our treatment need not be influenced thereby. Occasionally a volvulus, a intussusception, a band, or twist of the bowel, or a mesenteric thrombus may be found instead of a lesion of the appendix, but the symptoms will be grave, and an operation will be as certainly indicated, which of itself will, in all probability, clear up the diagnosis, as well as give the patient the best possible chance of recovery.

The most reliable and important symptoms of acute appendicitis are pain and tenderness in the abdomen. They are always present to a greater or less degree in the early stage of the affection, and the latter persists so long as the active process is going on. Of such vital importance is tenderness in the acute stage as a factor in the diagnosis, that its absence would make one hesitate to call the disease appendicitis, even were the other symptoms present to a marked degree. The only time the writer ever opened the belly for supposed appendicitis without finding it, was in the case of a middle-aged gentlemen, who had suffered severely for three or four days with pain in the bowels, requiring repeated doses of opiates. The abdomen was distended and tympanitic; there was paresis of the bowels, with obstinate constipation, grayish, shrunken skin, pinched features and prostration. He was evidently a very sick man, and apparently suffering from general peritonitis. For the past few years he had had several attacks of a similar character, but of less severity. There was little or no tenderness of the abdomen. The operation revealed a healthy appendix. The intestines were markedly congested, but free from lymph or adhesions. At the autopsy

nothing further was found to account for the symptoms. There was neither band, twist, intussusception or other lesion found upon a careful examination. The only sympton wanting in this case to complete the clinical picture of appendicitis was tenderness. It absence was fatal to the diagnosis.

Pain and tenderness then are the principal symptoms of appendicitis, which seldom fail to be present from the beginning; and their severity and persistency, as a rule, are an index to the gravity of the attack.

Tenderness is the main feature which distinguishes appendicitis from colic or functional affections of the abdominal organs. The pain is frequently as severe in the latter as in the former, it is not so persistent nor as prostrating in the functional as in the infiammatory affection.

In the early stages of appendicitis the pain is located in the vicinity of the navel rather than in the right inguinal region. This fact is very misleading to many physicians, who naturally expect to find it referred to the usual seat of the appendix. It is to be distinctly remembered, that both the pain and the tenderness may not be located in the region of the appendix for two or three days after the commencement of the disease. If, however, the patient is very sick and steadily growing worse, be assured that these symptons will sooner or later declare themselves in an unmistakable manner, thereby removing all doubt as to the character of the disease.

By way of summary it may be said, that the cases are rare in males and in young girls in which sudden, acute abdominal pain accompanied by tenderness on deep pressure upon the right side of the median line does not indicate a lesion of the appendix. The writer submits that this is a good working rule for everyday practice. The exceptions are so uncommon, and an early diagnosis is so important, that an occasional error resulting from its adoption will be readily overlooked by all concerned.

Rigidity of the abdominal muscles, more marked upon the right side, is an important symptom; and so is intestinal paresis, as inability to pass off gas by the rectum. Pulse, temperature, vomiting, restlessness and prostration will also demand attention. These symptoms, however, are all subordinate in importance for purposes of establishing a probable diagnosis to those above

mentioned, namely, pain and tenderness, which alone are worthy of the firm and most careful consideration. A person may be very sick with appendicitis, and still have nothing the matter with him, if the pulse and temperature alone are depended upon as an indication of his condition.

Occasionally a case is met with in which the symptoms are so slight and so evanescent, that it is only after observation of repeated attacks that the character of the affection can be ascertained with reasonable certainty.

Since this paper was written, a young woman was admitted to the City Hospital with what was supposed to be appendicitis. she had the symptoms of a pretty severe general peritonitis of two days' duration. It was the third attack within two months. There was sudden, severe pain in the abdomen, followed by vomiting, retention of flatus, fever and restlessness; tenderness was more marked on the left side of the median line. She had severe exacerbations every twelve hours.

On opening the peritoneal cavity the appendix was small, moderately congested and surrounded by recent adhesions. It was evidently not the focus of the present trouble, as the greater amount of congestion and discoloration was located in the region of the umbilicus. Here we found a firm band attached to a coil of the small intestines, and running down towards the pubes. This band was separated from the bowel, the appendix was removed, and the wound closed completely. She has made a satisfactory recovery. The only pecularity of the symptoms in this case at the time of operation, was that she did not seem to be quite as tender over the appendical region as you would expect her to be.

This case is mentioned merely to show, that occasionally on opening the peritoneal cavity for supposed lesions of the appendix, we do not find the exact conditions that the symptoms would lead us to expect. It does not militate against the treatment in any way, but on the contrary, it illustrates the wisdom of exploratory operations under certain circumstances.

The diagnosis of probable appendicitis having been established, the treatment of the patient is the next question to engage the attention of the family physician. This is the time, in the majority of instances, when he needs and should have the