The question of operation in appendicitis is a very live one nowadays and is being everywhere discussed. The medical profession has not yet come to a unanimous conclusion in regard to it. Surgical treatment of appendicitis originated in this country, Dr. Reginald Fitz of Boston having done the first operation for this purpose, and it has been practised and perfected here more than anywhere else. It is therefore quite natural that we find many more advocates of surgical intervention in America than abroad. As a general rule the majority of surgeons frequently recommend operative intervention, while the larger number of physicians reserve-the surgical treatment only for a small number of grave cases of appendicitis. Fowler, Morris, Beck, Deaver, Murphy, and others in this country and Legueu 1 in France urge surgical treatment in every case of appendicitis. Legueu says: "Appendicitis belongs to surgery." . . . "There is no medical treatment of appendicitis." . . . "Every appendicitis must be operated early." C. Beck2 expresses himself in the following manner: " No matter how mild the clinical picture of appendicitis appears, even if it promises a quick temporary recovery, the operation is always justified.

Inasmuch as the gravity of infection can never be estimated at the beginning, it appears wiser to look upon every case of appendicitis as serious. Of two evils one should choose the lesser, and the lesser one here means operation." In his article Beck makes the two following assertions: " 1. Appendicitis is a surgical disease and should be treated surgically as soon as diagnosed. 2. So long as no physician is able to estimate the gravity of the bacterial infection at the commencement of the disease or to foresee the course which the appendicitis will pursue, whether mild or grave, the safest treatment consists in the early removal of the appendix."

1 Felix Legueu: "Traitraent de l'Appendicite." Suite de Mono-graphies Cliniques, 1899, No. 80.

2 C. Beck: "Appendicitis. "Volkmann's Sammlung klinischer Vor-trage, No. 221, Sept.. 1898.

Many surgeons, even in this country, however, do not take so radical a view as the above writers. Thus Willy Meyer,1 Charles McBurney, W. T. Bull, A. J. McCosh and F. Hawkes,2 and others do not recommend the early operation in milder forms of appendicitis. McCosh and Hawkes express themselves in the following manner with regard to the necessity of operative interference: " When the presence of pus is assured, the sooner operation is done the better. Also there are cases which begin and continue for twenty -four or forty-eight hours with such severity that a judicious mind must conclude that operation is demanded. So in the chronic and relapsing cases where the symptoms have continued for months with such severity and have recurred so frequently as to subject the patient to a life of semi-in-validism, no wise surgeon can counsel any other plan of treatment than removal of the diseased appendix. Likewise when the patient has suffered from three or more attacks the offending organ should be removed, for other attacks will in all probability follow. The same indication for operation also exists in our opinion if a patient has suffered from two attacks within a year or even two years." ..." The view which we take is that operation is not necessary in every case of appendicitis.

We believe that not infrequently patients recover, and recover permanently, from one attack of appendicitis, and that in a certain number of cases, provided a careful watch is kept, operation is not necessary. On the other hand, we acknowledge that many cases which did not appear to be serious have been allowed to die when they might have been saved by operation."

1 Willy Meyer: " When Shall we Operate for Appendicitis? " Medical Record, February 29. 1896.

2 A. J. McCosh and F. Hawkes: " The Surgical Treatment for Appendicitis. " The American Journal of the Medical Sciences, May, 1897.

Willy Meyer, who was among the first to recommend the removal of the appendix during the free interval, comes to the following conclusions in his paper already mentioned: "1. In case of diffuse perforative appendicitis the operation must always be done at once. 2. In cases of acute appendicitis the patient always needs careful observation. If the pulse goes above 116 and 120 and has a tendency to stay there, the indication for an operation is given. In cases of doubt the operation is better than waiting. In cases of subacute attacks of appendicitis, also after the first severe attack from which the patient recovers without immediate operation, the appendix should be removed. The appendix once inflamed has to be looked upon as a diseased organ which is very apt to give repeated and more serious, even fatal, trouble in the future."

Among the German surgeons Sonnenburg, and especially Riedel,1 are advocates of early surgical intervention in the grave forms of appendicitis. Riedel says: "As soon as the temperature reaches 101°, the pulse 100, the immediate removal of the appendix is indicated. ... A tumor which has developed, accompanied by fever and an acceleration of the pulse, is always an indication for immediate operation." R. Stein2 and Henry J. Wolf,3 in papers read quite recently before the German Medical Society of New York, urged early surgical intervention in all the graver forms of appendicitis.

With Penzoldt, Nothnagel, Ewald, Boas, and others I would give the following indications for surgical intervention in this disease:

1 Riedel: "Ueber die sog. Fruhoperation bei Appendicitis puru lenta resp. gangraenosa." Berliner klinische Wochenschrift, 1899, 33 und 34.

2 R. Stein: Deutsche med. Wochenschr., 1899, p. 440.

3 H. J. Wolf: New Yorker medicinische Monatsscbrift, 1899.

1. Diffuse peritonitis in consequence of perforation of the appendix demands immediate operation. As a rule the following symptoms will be found: Sunken and drawn features, cyanosis, a small and very frequent pulse, an increase of the painful area, often also a bloated condition of the abdomen.

2. Whenever an appendicular abscess showing fluctuation is present, an operation should be performed.

3. If the protracted course of the disease points to the existence of an abscess, giving rise to slight septic symptoms, an operation should be undertaken.

While in these three groups there can be no hesitation in recommending the operation, in the following groups the necessity of surgical intervention must be considered and decided in each individual case.

4. (a) If the rational treatment does not produce any improvement in the course of three to five days, the symptoms persisting in undiminished severity or becoming even more pronounced, an operation may be resorted to. (b) A sudden rise of temperature lasting over twenty-four hours, after the first few days of sickness, is also an indication for operation, (c) A very frequent pulse, not corresponding to the degree of fever, is another symptom which justifies the consideration of an operation, (d) If the tumor continues to increase in size after the fifth day of sickness, an operative treatment should be considered.

5. The removal of the appendix should be undertaken: (a) In all cases of appendicitis in which after recovery the pain in the right iliac region persists for a long time (several months); (b) in recurrent appendicitis if the attacks have been quite severe or if they have followed each other at short intervals.