aid and the support of the surgeon. I want to say here and now in the strongest possible manner, that every case of probable or possible appendicitis in which the symptoms are grave or protracted had better be seen by one who is familiar with the disease who is accustomed to operating for its relief, for the following reasons: 1. to confirm or establish the diagnosis; 2. to divide and share the responsibility; 3. to get at the real condition of the patient at the earliest moment practicable, that his measure, so to speak, may be taken before he gets into a dangerous, and hence unsatisfactory, condition; 4. that the patient may have the benefit of early observation by one who is to decide upon the necessity of an operation and the proper time for its performance; and, finally, for the satisfaction of the friends, as well as for the protection of the regular attendant in the future in case the result should be disastrous. It is seldom that a useless or premature consultation is called in this disease. Too often the surgeon, though no fault of the family physician, is summoned too late to be of any service, except to convey to the anxious friends a statement of the unfortunate condition of affairs, and to offer what consolation he may under the circumstances. Early, and if necessary, frequent consultations should be the rule in all but the very lightest cases of appendicitis.

The laity are now so familiar with this affection, and have such a horror of it, and justly so, that any error in judgment in this direction is not laid up against us. Hence I would urge all physicians who are not pretty familiar with this disease, and who do not feel reasonably certain that their patient's condition, to call a surgeon early. Put him on the case in line with yourself; keep him posted as to the progress of the symptoms, and summon him whenever you are in doubt as to the true state of affairs. See your patient every six to twelve hours. Because he is comfortable at one visit, do not take it for granted that he will be at your next.

Look out for exacerbations. They mean a fresh extension of the infection, a further invasion of the peritoneum, and a greater menace to the welfare of the patient. You are dealing with one of the most treacherous of known diseases, insidious in its manifestations uncertain in its career, and liable to sudden changes, which at any moment may put the patient in a condition of ex

treme peril. Given a case of appendicitis of any severity, your vigilance can not he too active nor your precautions too complete to guard the patient against the various accidents and misfortunes liable to befall him.

I may be permitted to digress for a few moments to speak more at length upon the proper treatment to be pursued in the earliest stages of this affection. You are called to a person suffering from pain and tenderness in the abdomen, which in your opinion indicate a lesion of the appendix, What shall be your first treatment? Will you give laxatives or an opiate? Many physicians would recommend the former, most surgeons the latter. If the pain is at all severe, I not only advise, but I urge you to give sufficient morphine under the skin to relieve the pain. That is the symptom which you are called to treat, and for the time being it overshadows everything else. Relieve the immediate distress, and then take time to consider as to what further treatment is necessary. The amount of opiate required to effect his object varies in different cases, and is often an index of the severity of the attack, and of the danger to be apprehended.

A

In fortunate cases the pain once subdued in this manner does not return, as was shown in the following instance: A young gentlemen was recently seized with severe pain in the bowels, while in the recitation-room at college. He was obliged to leave the class, and started for home. The pain become so unbearable, that he got off the electric car, crawled into the nearest physician's office, threw himself upon the floor, and rolled in agony. A half-grain of morphia under the skin relieved him completely in a short time. He at once entered the City Hospital, and remained about a week, having no further trouble, save a slight tenderness or uneasiness in the appendiceal region upon deep pressure or in certain movements,

This gentleman was naturally anxious about the future. He was told that in our opinion he was liable to have another attack at almost any time, and that it might be even more severe than the present one, and less readily amenable to treatment. It was for him to decide whether he would risk it or not. Our advice was that he should wait a few weeks or until every vestige of this attack had passed away, and then have the appendix re

moved. The operation was done inside of a month, and the appendix was found to be the seat of marked catarrhal inflammation. He made a quick and satisfactory recovery.

Now, no judicious physician could hesitate for an instant on purely theoretical grounds to give morphine, or some other quick opiate, in a case like this. To abolish the pain, remove suffering, and thereby save nerve force is plainly our first duty. As it requires a long time for sufficient opiate to be absorbed from the stomach of a person in great pain, it is far better to put it under the skin in the form of morphia. It is thus quickly and surely taken up, and we are not long left in doubt as to its effects. So much for the initial treatment of appendicitis in the severe cases. What shall it be in those instances, of which there are many, where the pain is moderate in severity, and hence the necessity for immediate relief is not so urgent? Shall opium or laxatives be given? Experience teaches us beyond a doubt, that many cases recover under both methods of treatment; and yet, in my opinion, there is a very decided preference in favor of the former or sedative plan. Having been a victim to this disease at intervals for eighteen years, and having twice undergone laparotomy for its relief, the writer feels that he can express an opinion upon this point with some confidence. While relief may follow the administration of castor-oil or other laxative in the lighter cases, yet the severe ones are more oftener made worse by such medication. Opium judiciously given seldom, if ever, does harm under these circumstances; laxatives oftentimes do great injury, and may turn the scale against recovery. There can be little doubt that the former is the safer and better plan. The writer claims that opiates will relieve every case that laxatives or cathartics will, and very many cases that the latter will not relieve. For these reasons he can not urge you too strongly to depend upon opiates for the relief of pain in the first stages of appendicitis. It is claimed that opiates mask the symptoms in this affection, and may thus mislead the physician as to the patient's real condition. While this may be true to a limited extent, yet any one accustomed to seeing and studying this disease can form a reasonably correct opinion of the case by making due allowance for the effect of the drug. In rare instances a few hours' delay might be desirable, before a final decision is reached. At

all events, this objection is not often a valid one in every-day practice.

For the pain of appendicitis, then, opiates are our main reliance in our earliest stages; but we must not depend upon them for too long a period, or the golden opportunity for permanent relief may pass away never to return. Here comes in one of the most difficult questions of the whole subject for decision, to wit, When shall medical treatment be supplanted by surgical, or, in other words, when shall an operation be resorted to?

The indications may be briefly stated as follows: In very severe cases an operation is called for within twenty-four hours, or, at the outside, forty-eight hours from the commencement of the seizure. In cases of moderate severity, with no signs of amelioration of the symptoms on the third or fourth day, an operation is usually indicated. In relapsing cases, in from seven to fourteen days, according to the urgency of the symptoms. In recurring cases, after the first attack is entirely recovered from, say in from four to eight weeks, if the symptoms were severe, or after the second attack if the symptoms were only of moderate severity. It is to be borne in mind that these periods are only approximate, and not intended to be exact by any means, as each case is to be decided upon its own merits and manifestations. No affection calls for more careful consideration, a clearer understanding and calmer judgment than appendicitis.

It may be said here, tha: persons having a damaged appendix should be careful about traveling in foreign countries, as the physicians do not seem to be as familiar with this disease as are the American physicians. It is said to be more prevalent here than in other countries for reasons not yet satisfactorily explained.

In as brief a manner as possible, the particular conditions and circumstances, in which a surgeon should be summoned in consultation, will now receive consideration.

1. In cases of the fulminating variety of appendicitis, in which the symptoms are always grave, and generally becoming worse from hour to hour to an alarming degree, it is scarcely possible to obtain surgical aid too early in the disease. An operation may, or may not, be necessary, according to the condition of the patient; but from the very nature of things, an experienced surgeon is the best able to decide that point. No one

would think of operating upon a person while in a state of profound collapse. The proper treatment for one in that condition is hypodermic and rectal stimulation and external heat. If he cannot be rallied in that way, he certainly cannot be by an opertion. Profound prostration, which differs from collapse in that the clammy sweats, cold extremities, flickering pulse and sighing respiration are lacking, may call imperatively for an immediate operation. By speedily relieving the system of the pent-up septic materials the vital powers are thus enabled to rally, and to regain their normal condition. Hence, in these cases of sudden and severe seizure, you want all the aid you can get, and you want it Don't wait till to-morrow.

at once.

It may be said here, that, contrary to what might be inferred from some writers of the present day, an operation, however early it may be performed, will not save every case of appendicitis. A small proportion of the victims of this disease will perish whatever may be the treatment, and however promptly and thoroughly it may have been adopted. Operations performed within twelve hours of the onset of appendicitis have failed to give the slightest relief. And yet this fact should not discourage early operations, when they are indicated, for in very many instances the convalescence dates from the time of the operation. It is simply a reminder that too much must not be expected from surgical measures.

2. The greater proportion of cases of appendicitis met with in ordinary practice will probably come under this head. The symptoms are moderate in severity at first, but steadily grow worse every twelve hours or so, with perhaps occasional remissions. These cases are often very deceptive. The patient does not seem to be very sick. With an occasional opiate, or perhaps without anything of the sort, he suffers little pain; and the attendants and friends are loath to believe that a serious, if not a dangerous, process is going on in the abdomen, until the vital powers are so exhausted that the patient's chances for recovery are very materially diminished.

urge that the surgeon be

In these cases I should strongly called not later than the third day. Very likely the symptoms will be only of moderate severity at that time; but the consultant can form a much more correct and satisfactory idea of the char