APPENDICITIS, OR NATURE’S REMNANT SALE

We were not made all at once, nor do we go to pieces all at once, like the “one-hoss shay.” This is largely because we are not all of the same age, clear through. Some parts of us are older than other parts. We have always felt a difficulty, not to say a delicacy, in determining the age of a given member of the human species-especially of the gentler sex. Now we know the reason of it. From the biologic point of view, we are not an individual, but a colony; not a monarchy, but a confederacy of organ-states, each with its millions of cell-citizens. It is not merely editors and crowned heads who have a biologic right to say “We.” Therefore, obviously, any statement that we make as to our age can be only in the nature of an average struck between the ages of our heart, lungs, liver, stomach; and as these vary in ancientness by thousands of years, the average must be both vague and misleading. The only reason why there is a mystery about a woman’s age is that she is so intensely human and natural. The only statement as to our age that the facts would strictly justify us in making must partake of the vagueness of Mr. A. Ward’s famous confession that he was “between twenty-three summers.”

As we individually climb our own family-tree, from the first, one-celled droplet of animal jelly up, none of our organs is older than we are, but a number of them are younger. The appendix is one of these. Now, by some curious coincidence, explain it as we may, some of our oldest organs are youngest, in the sense of most vigorous, elastic, and resisting, while some of our youngest are oldest, in the sense of decrepit, feeble, and unstable. It is perhaps only natural that an organ like the stomach, for instance, which has a record of honorable service and active duty millions of years long, should be better poised, more reliable, and more resourceful than one which, like the lung or the appendix, has, as it were, a “character” of only about one-tenth of that length. However this may be, the curious fact confronts us that scattered about through the body are structures and fragments, the remains of organs which at one time in our ancestral career were, under the then existing circumstances, of utility and value, but have now become mere survivals, remnants,-in the language of the day, “back numbers.” Some of these have still a certain degree of utility, though diminished and still diminishing in size and functional importance, like our third molars or “wisdom” teeth, our fifth or “little” toes, our gall-bladder, our coccyx or tail-bone, the hair-glands scattered all over the now practically hairless surface of our bodies, and our once movable ears, which can no longer be “pricked,” or laid back. These, though of far less utility and importance than they obviously were at one time, still earn their salt, and, though all capable of causing us considerable annoyance on slight provocation, seldom give rise to serious trouble or inconvenience. There are, however, a few of these “oversights” which are of little or no known utility, and yet which, either by their structure or situation, may become the starting-point of serious trouble.

The best known members of this small group are the openings through the abdominal wall, which, originally placed at the strongest and safest position in the quadrupedal attitude, are now, in the erect attitude, at the weakest and most dangerous, and furnish opportunity for those serious and sometimes fatal escapes of portions of the intestines which we call hernia; the tonsils; and our friend the appendix vermiformis.

For once its name expresses it exactly. It is an “appendix,” an afterthought; and it is “vermiformis,” a worm-like creature,-and, like the worm, will sometimes turn when trodden on. Its worm-likeness is significant in another sense also, in that it is this very diminutiveness in size-the coils into which it is thrown, the spongy thickness of its walls, and the readiness with which its calibre or its circulation is blocked-that is the fundamental cause of its tendency to disease.

The cause of appendicitis is the appendix.

“Despise not the day of small things” is good pathology as well as Scripture. Here we have a little, worm-shaped tag, or side branch, of the food-tube, barely three or four inches long, of about the diameter of a small quill and of a calibre that will barely admit an ordinary knitting needle. And yet we speak of it with bated breath. When we remember that this little, twisted, blind tube opens directly out of one of the largest pouches of the intestines (the caecum), and that it is easy for anything that may be present in the large pouch-food, irritating fragments of waste matter, or bacteria-to find its way into this fatal little trap, but very difficult to find the way out again, we can form some idea of what a literal death-trap it may become.

How did such a useless and dangerous structure ever come to develop in a body in which for the most part there is mutual helpfulness, utility, and perfect smoothness of working through all the great machine? To attempt to answer this would carry us very far back into ancient history. But to make such backward search is absolutely the only means of reaching an answer.

“But,” some one will object, “how perfectly irrational, not to say absurd, to propose to go back hundreds of thousands of years into ancient history, to account for a disease which has been discovered-according to some, invented-within the past twenty-five years!”

Appendicitis is a mark, not a result, of a high grade of civilization. To have had an operation for it is one of the insignia of modern rank and culture. Our new biologic aristocracy, the “Appendix-Free,” look down with gentle disdain upon their appendiciferous fellows who still bear in their bodies this troublesome mark of their lowly origin. In short, the general impression prevails that appendicitis is a new disease, a disease which has become common, or perhaps occurred at all, only within the last quarter of a century, and which therefore-with the usual flying leap of popular logic-is a serious menace to our future, if it keeps on increasing in frequency and ferocity at anything like the same rate which it has apparently shown for the past fifteen years.

As this feeling of apprehension is in many minds quite genuine, it may be well to say briefly, before proceeding further, first, that, if there be any disease which absolutely and almost exclusively depends upon definite peculiarities of structure, it is appendicitis, and that these structural peculiarities of this tiny, cramped tag of the food-canal have existed from the earliest infancy of the race. So it is almost unthinkable that man should not have been subject to fatal disturbances of this organ from the very earliest times. On the post-mortem table, the appendix of the lowest savage is the same useless, shriveled, and inflammable worm as that of the most highly civilized Aryan, though perhaps an inch or so longer. Secondly, there is absolutely no adequate proof that appendicitis is increasing in frequency among civilized races. It is only about twenty-five years ago that it was first definitely described, and barely fifteen that the profession began at all generally to recognize it.

But all of us whose memory extends backward a quarter of a century can clearly recall that, while we did not see any cases of “appendicitis,” we saw dozens of cases of “acute enteritis,” “idiopathic (self-caused) peritonitis,” “acute inflammation of the bowels,” “acute obstruction of the bowels,” of which patients died both painfully and promptly, and which we now know were really appendicitis.

In short, from a careful study of all the data, including the claims so frequently made of freedom from appendicitis on the part of Oriental races, colored races, less civilized tribes, vegetarians, and others, we are tending toward the conclusion that the percentage of appendicitis in a given community is simply the percentage of its recognition,-in other words, of the intelligence and alertness, first of its physicians, and then of its laity. As an illustration, my friend Dr. Bloodgood kindly had the statistics of the surgical patients treated in the great Johns Hopkins Hospital at Baltimore investigated for me, and found almost precisely the same percentage of cases of appendicitis among colored patients as among white patients.

The earlier impression, first among physicians and now in the laity, that appendicitis is an almost invariably fatal disease, is not well founded, and we now know that a large percentage of cases recover, at least from the first attack; so that it is quite possible for from half to two-thirds of the cases of appendicitis actually occurring in a given community to escape recognition, unless promptly reported, carefully examined, and accurately diagnosed. Thirdly, in spite of the remarkable notoriety which the disease has attained, the general dread of its occurrence,-which has been recently well expressed in a statement that everybody either has had it, or expects to have it, or knows somebody who has had it,-the actual percentage of occurrence of grave appendicitis is small. In the United States census of 1900, which was the first census in which it was recognized as a separate cause of death, it was responsible for only 5000 deaths in the entire United States for the ten years preceding, or about one death in two hundred. This rate is corroborated by the data, now reaching into thousands, from the post-mortem rooms of our great hospitals, which report an average of between a half and one per cent. A disease which, in spite of the widespread terror of it, kills only one in two hundred of those who actually die-or about one in every ten thousand of our population-is certainly nothing to become seriously excited over from a racial point of view.

While appendicitis is one of the “realest” and most substantial of diseases, and, in its serious form, highly dangerous to life, there can be little doubt that there has come, first of all, a state of mind almost approaching panic in regard to it; and, second, a preference for it as a diagnosis, as so much more distingue than such plebeian names as “colic,” “indigestion,” “enteritis,” or the plain old Saxon “belly-ache,” which has reached almost the proportions of a fad. It is certain that nowadays physicians have almost as frequently to refuse to operate on those who are clamoring for the distinction, as to urge a needed operation upon those unwilling to submit to it.

The satirical proposal that a “closed season” should be established by law for appendicitis as for game birds, during which none might be taken, would apply almost as often to the laity as to the profession, even the surgical half.

Since the chief cause of appendicitis is the appendix, the first question for disposal is, How did the appendix become an appendix? To this biology can render a fairly satisfactory answer. It is the remains of one of Mother Nature’s experiments with her ’prentice hand upon the mammalian food-tube. As is now generally known, the food-canal in animals was originally a comparatively straight tube, running the length of the body from mouth to anus. It early distends into a moderate pouch, about a third of the way down from the mouth, forming a stomach, or storage and churning-place for the food. Below this, it lengthens into coils (the so-called small intestine), which, as the body becomes more complex, increase in number and length until they reach four to ten times the length of the body. Later, the lower third of the tube distends and sacculates out into a so-called large intestine, in which the last remnants of nutritive material and of moisture are extracted from the food-residues before they are discharged from the body. Just at the junction of this large intestine with the small intestine, nature took it into her head to develop a second pouch, a sort of copy of the stomach. This pouch, from the fact that it ends in a blind sac, is known as the caecum (or “blind” pouch), and is apparently simply a means of delaying the passage of the foodstuffs until all the nutriment and moisture have been absorbed out of them for the service of the body. Naturally, it has developed to the largest degree and size in those animals which have lived upon the bulkiest and grassiest of foods, the so-called Herbivora, or grass-eaters. In the Carnivora, or flesh-eaters, it is usually small, and in one family, the bears, entirely absent. This pouch is no mere figure of speech, as may be gathered from the fact that in certain of the rodent Herbivora, like the common guinea-pig, it may have a capacity equal to all of the rest of the alimentary canal, and in the horse it will hold something like four times as much as the stomach. Oddly enough, among the grass-eaters, for some reason which we do not understand, it appears to occur in a sort of inverse proportion to the stomach; those which have large, sacculate, pouched stomachs, like the cow, sheep, and the ruminants generally, having smaller caeca. In other Herbivora with small stomachs, like the rabbit and the horse, it develops greater size.

Our primitive ancestors were mixed feeders, and, though probably more largely herbivorous than we are to-day, had a medium-sized caecum, and maintained it up to the point at which the anthropoid apes began to branch off from our family-tree. But at about this point, for some reason, possibly connected with the increasing variety and improved quality and concentration of the food, due to greater intelligence and ability to obtain it, this large caecum became unnecessary, and began to shrivel.

Here, however, is where nature makes her first afterthought mistake. Instead of allowing this pouch to contract and shrivel uniformly throughout its entire length, she allowed the farther (or distal) two-thirds of it to shrivel down at a much faster rate than the central (or proximal) third; so that the once evenly distended sausage-shaped pouch, about six to eight inches long and two inches in diameter, has become distorted down into a narrow, contracted end portion, about a quarter of an inch in diameter, and a distended first portion, for all the world like a corncob pipe with a crooked stem and an unusually large bowl. And behold-the modern appendix vermiformis, with all its fatal possibilities!

If we want something distinctly human to be proud of, we may take the appendix, for man is the only animal that has this in its perfection. A somewhat similarly shriveled last four inches of the caecum is found in the anthropoid apes and in the wombat, a burrowing marsupial of Australia. In some of the monkeys, and in certain rodents like the guinea-pig, a curious imitation appendix is found, which consists simply of a contracted last four or five inches of the caecum, which, however, on distention with air, is found to relax and expand until of the same size as the rest of the gut.

The most strikingly and distinctly human thing about us is not our brain, but our appendix. And, while recognizing its power for mischief, it is only fair to remember that it is an incident and a mark of progress, of difficulties overcome, of dangers survived. In all probability, it was our change to a more carnivorous diet, and consequently predatory habits, which enabled our ancestors to step out from the ruck of the “Bandar-Log,” the Monkey Peoples. An increase in carnivorousness must have been a powerful help to our survival, both by widening our range of diet, so that we could live and thrive on anything and everything we could get our hands on, and by inspiring greater respect in the bosoms of our enemies. Let us therefore respect the appendix as a mark and sign of historic progress and triumph, even while recognizing to the full its unfortunate capabilities for mischief.

But what has this ancient history to do with us in the twentieth century? Much in every way. First, because it furnishes the physical basis of our troubles; and second, and most important, because, like other history, it is not merely repeating itself, but continuing. This process of shriveling on the part of the appendix is not ancient history at all, but exceedingly modern; indeed, it is still going on in our bodies, unless we are over sixty-five years of age.

In the first place, we have actually passed through two-thirds of this process in our own individual experience.

At the first appearance of the caecum, or blind pouch, in our prenatal life, it is of the same calibre as the rest of the intestine, and of uniform size from base to tip. About three weeks later the tip begins to shrivel, and from this on the process steadily continues, until at birth it has contracted to about one-fifteenth of the bulk of the caecum. But the process doesn’t stop here, though its progress is slower. By about the fifth year of life the stem of the caeco-appendix pipe has diminished to about one-thirtieth of the size of the bowl, which is the proportion that it maintains practically throughout the rest of adult life. For a long time we concluded that the process was here finished, and that the appendix underwent no further spontaneous changes during life; but, after appendicitis became clearly recognized, a more careful study was made of the condition of the appendix in bodies coming to the post-mortem table, dead of other diseases, at all ages of life. This quickly revealed an extraordinary and most significant fact, that, while the appendix was no longer decreasing in apparent size, its internal capacity or calibre was still diminishing, and at such a rate that by the thirty-fifth year it had contracted down so as to become cut off from the cavity of the caecum in about twenty-five to thirty per cent of all individuals. By the forty-fifth year, according to the anatomist Ribbert (who has made the most extensive study of the subject), nearly fifty per cent of all appendices are found to be cut off, and by the sixty-fifth year nearly seventy per cent.

This explains at once why appendicitis is so emphatically a disease of young life, the largest number of cases occurring before the twenty-fifth year (fifty per cent of all cases occur between ten and thirty years of age), and becoming distinctly rarer after the thirty-fifth, only about twenty per cent occurring after this age. As soon as the cavity of the appendix is cut off from that of the intestine, it is of course obvious that infectious or other irritating materials can no longer enter its cavity to cause trouble, although, of course, it is still subject to accidents due to kinks, or twists, or interference with its blood-supply; but these are not so dangerous, providing there be no infectious germs present.

Here, then, we have a clear and adequate physical basis for appendicitis. A small, twisted, shriveling spur or side twig of the intestine, opening from a point which has become a kind of settling basin in the food-tube, its mouth gaping, as it were, to admit any poisonous or irritating food, infectious materials, disease-germs, the ordinary bacteria which swarm in the alimentary canal, or irritating foreign bodies, like particles of dirt, sand, hairs, fragments of bone, pins, etc., which may have been accidentally swallowed. Once these irritating and infectious materials have entered it, spasm of its muscular coat is promptly set up, their escape is blocked, and a violent inflammation easily follows, which may end in rupture, perforation, or gangrene.

Not only may any infection which is sweeping along the alimentary canal, thrown off and resisted by the vigorous, full-sized, well-fed intestine, find a point of lowered resistance and an easy victim for its attack in the appendix, but there is now much evidence to indicate that the ordinary bacteria which inhabit the alimentary canal, particularly that first cousin of the typhoid bacillus, the colon bacillus, when once trapped in this cul-de-sac, may quickly acquire dangerous powers and set up an acute inflammation. It is not necessary to suppose that any particular germ or infection causes appendicitis. Any one which passes through, or attacks, the alimentary canal is quite capable of it, and probably does cause its share of the attacks.

Numerous attempts have been made to show that appendicitis is particularly likely to follow typhoid fever, rheumatism, influenza, tonsilitis, and half a dozen other infectious or inflammatory processes. But about all that has been demonstrated is that it may follow any of them, though in none with sufficient frequency or constancy to enable it to be regarded as one of the chief or even one of the important causes of the disease.

One dread, however, we may relieve our anxious souls of, and that is the famous grape-seed or cherry-stone terror. To use a Hibernianism, one of our most positive conclusions in regard to the cause of appendicitis is a negative one: that it is not chiefly, or indeed frequently, due to the presence of foreign bodies. This was a most natural conclusion in the early days of the disease, since, given a tiny blind pouch with a constricted opening gaping upon the cavity of the food-canal, nothing could be more natural than to suppose that small irritating food remnants or foreign bodies, slipping into it and becoming lodged, would block it and give rise to serious inflammation. And, moreover, this a priori expectation was apparently confirmed by the discovery, in many appendices removed by operation, of small oval or rounded masses, closely resembling the seed of some vegetable or fruit. Whereupon anxious mothers promptly proceeded to order their children to “spit out,” with even more religious care than formerly, every grape-seed and cherry-stone. The increased use of fresh and preserved fruits was actually gravely cited, particularly by our Continental brethren, as one of the causes of this new American disease. Barely ten years ago I was spending the summer in the Adirondacks, and was bitterly reproached by the host of one of the Lake hotels, because the profession had so terrified the public about the dangers of appendicitis from fruit-seeds that he was utterly unable to serve upon his tables a large stock of delicious preserved and canned raspberries, blackberries, and grapes which he had put up the previous years. “Why,” he said, “more than half the people that come up here will no more eat them than they would poison, for fear that some of the seeds will give ’em appendicitis.” This dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these “foreign bodies” were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous masses of the faeces.

We are in a nearly similar position in regard to the third alleged cause of appendicitis, and that is food. Many are the accusations which have been made in this field. On the one hand, meat and animal foods generally have been denounced, on account of their supposed “heating” or “uric-acid-forming” properties; while on the other, vegetables and fruits have been equally hotly incriminated, on account of their seeds, fibres, husks, and irritating substances, and the danger of their being contaminated by bacteria and other parasites from the soil. These charges appear to have little adequate foundation, and, so far as we are in a position now to judge, the only way a food can give, or be accessory to, appendicitis is by its being taken in such excessive amounts as to set up fermentive or putrefactive changes in the alimentary canal, or by its being in an unsound, decaying, or actually diseased condition. Any amounts or quality of food which are capable of giving rise to an attack of acute indigestion may secondarily lead to an attack of appendicitis. The only single article of diet whose ingestion is declared by Osler to be rather frequently followed by an attack of appendicitis is the peanut.

Therefore, the best thing to do in the way of taking precautions against the occurrence of appendicitis is, in the language of the day, to “forget it” as completely as possible, reassuring ourselves that, in spite of its extraordinary notoriety and popularity, it is a comparatively rare disease in its fatal form, responsible for not more than one-half of one per cent of the deaths, and that the older we grow, the better become our chances of escaping it.

Whatever we may have decided in regard to our brains, by the time we reach fifty, we may feel reasonably sure we’ve no appendix.

But the question will at once arise, if the appendix be so tiny in size, so insignificant in capacity, and so devoid of useful function, what is the use of disturbing ourselves over the question of what may become of it? If it is going to decay and drop off, why not permit it to do so, with the philosophic indifference with which we would sacrifice the tip of our little fingers in a planing-mill? Here, however, is just the rub, and the fact that gives to appendicitis all its terrors, and to the question of what to do in each particular case its difficulties and perplexities.

The appendix does not, unfortunately, hang out from the surface of the body, where it could peacefully decay and drop off without prejudice to the rest of the body, or be quickly lopped off in the event of its giving trouble. On the contrary, it projects its stubby and insignificant length right into the midst of the most delicate and susceptible cavity of the body, the general cavity of the abdomen, or peritoneum. The thin, sensitive sheet of peritoneum which lines this cavity covers every fold and part of the food-tube, from the stomach down to the rectum. And when once infection or inflammation has occurred at any point in it, there is nothing to prevent its spreading like a prairie fire, all over the entire abdominal cavity from diaphragm to pelvis. If this wretched little remnant were a coil of explosive fuse within the brain-cavity itself, which any jar might set off, it could hardly be richer in possibilities of danger.

A redeeming feature of appendicitis is that the appendix lies-so to speak-in a corner, or wide-mouthed pouch, of the great peritoneal cavity; and if the inflammation set up in it can be “walled off” from the rest of the peritoneal cavity, and limited strictly to this little corner or pouch, all will be well. This is what occurs in those cases of severe appendicitis which spontaneously recover. If, however, this disturbance bursts its barriers, and lights up an inflammation of the entire peritoneal cavity, then the result is likely to be a fatal one. Just how far nature can be trusted in each particular case to limit and stamp out the process in this manner is the core of the problem that confronts us, as attending physicians.

In the majority of cases, fortunately, the peritoneal fire brigade acts promptly, pours out a wall of exudate, and locks up the appendix in a living prison, to fight out its own battles and sink or swim by itself. But unfortunately, in a minority of cases, by a wretched sort of “senatorial courtesy” which exists in the body, the appendix is given its ancestral or traditional rights and allowed to inflict its petty troubles upon the entire abdominal cavity, and include the body in its downfall.

Lastly come the two most pertinent and appealing questions:-

What is the outlook for me if I should develop appendicitis? And what is to be done?

In regard to the first of these, it is safe to say that our answer is much less alarming than it was in the earlier stage of our knowledge. Naturally enough, in the beginning, only the severest and most unmistakable forms of the disease and those which showed no tendency to localization, were recognized, or at least came under the eye of the surgeon; and as a large percentage of these resulted fatally, the conclusion was reached, both in the medical profession and by the laity, that appendicitis was an exceedingly dangerous disease, with a high fatality in all cases. As, however, physicians became more expert in the recognition of the disease, it was discovered to be vastly more common, while side by side came the consoling knowledge that a considerable percentage of cases got well of themselves, in the sense of the inflammation being limited to the lower right-hand corner of the abdominal cavity, though, of course, with the possibility of leaving a smouldering fuse which might light up another explosion under any stress in future.

Further, as the attention of the post-mortem investigators at our large hospitals was directed to the subject, it was found that a very considerable percentage of all bodies, ranging from twenty to-according to some estimates-as high as sixty per cent, showed changes in the appendix and its neighborhood which were believed to be due to old inflammations; so that, while it is possible to speak only with great caution and reserve, the balance of opinion among clinicians and pathologists of wide experience and the more conservative surgeons appears to be that from one-half to two-thirds of all cases of appendicitis will recover of themselves, in the sense of subsiding more or less permanently, without causing death.

On the other hand, it must be remembered that the appendix is an organ which, so far as any evidence has been adduced, is entirely without useful function; that it is in process of shriveling and disappearance, if left entirely alone, and that the best result which can be expected from a self-cured attack of appendicitis is the destruction of the appendix and its elimination as a further possible cause of mischief. By avoiding an operation in appendicitis, we may be practically certain that we save nothing that is worth saving-except the fee. Moreover, even though only from one-fourth to one-third of all cases develop serious complications, you never can be quite sure in which division your particular case will fall.

The situation is in fact a little bit like one related in the experience of Edison, the inventor. The trustees of a church in a neighboring town had just completed a beautiful new church building with a high spire, projecting far above any other building in the town. When it was nearing completion, the question arose, should they put on a lightning-rod. The great church itself had strained their financial resources, and one party in the board were of the opinion that they should avoid this unnecessary expense, supporting their economic attitude by the argument that, to put on a lightning-rod, would argue a lack of trust in Providence. Finally, after much debate, it was decided, as the great electrician was readily accessible, to submit the question to him. Mr. Edison listened gravely to the arguments presented, pro and con.

“What is the height of the building, gentlemen?”

The number of feet was given.

“How much is that above that of any surrounding structures?”

The data were supplied.

“It is a church, you say?”

“Yes.”

“Well,” said the great man, “on the whole, I should advise you to put on a lightning-rod. Providence is apt to be, at times, a trifle absent-minded.”

The chances are in favor of your recovery, but-put on a lightning-rod, in the shape of the best and most competent doctor you know, and be guided entirely by his opinion. An attack of appendicitis is like shooting the Grand Lachine Rapids. Probably you will come through all right; but there is always the possibility of landing at a moment’s notice on the rocks or in the whirlpools. With a good pilot your risk doesn’t exceed a fraction of one per cent. And fortunately this condition has been not merely theoretically but practically reached already; for the later series of case-groups of appendicitis treated in this intelligent way by cooeperation between the physician and surgeon from the start, with prompt interference in those cases which to the practiced eye show signs of making trouble, has reduced the actual recorded mortality of the disease to between two and five per cent. Even of those cases which come to operation now, the death-rate has been reduced as low as five per cent, in series of from 400 to 600 successive operations. When we contrast this with the first results of operation, when the cases as a rule were seen too late for the best time of interference, and from twenty per cent to thirty per cent died; and with the intermediate stage, when surgeons as a rule were inclined to advise operation at the earliest possible moment that the disease could be recognized, and from ten per cent to fifteen per cent died, we can see how steady the improvement has been, and how encouraging the outlook is for the future.

Cases which have weathered one attack of appendicitis are of course by no means free from the risk of another. Indeed, at one time it was believed that a recurrence was almost certain to occur. Later investigations, based upon larger numbers of cases, now running up into the thousands, give the reassuring result that though this danger is a real one, it is not so great as it was at one time supposed, as the average number in whom a second attack occurs appears to be about twenty per cent. This, however, is a large enough risk to be worthy of serious consideration; and in view of the fact that the mortality of operations done between attacks is less than one per cent, it is generally the feeling of the profession that, where there is any appreciable soreness, or tenderness, or liability to attacks of pain in the right iliac region, in an individual who has had one attack of appendicitis, the really conservative and prudent procedure is to have the source of the trouble removed once and for all.

The four principal symptoms of appendicitis are: pain, which is usually felt most keenly somewhere between the umbilicus and the right groin, though this is by no means invariable; tenderness in that same region upon pressure; rigidity of the muscles of the abdominal wall on the right side; and temperature, or fever.

No matter how much and how variegated pain you may have in the abdomen, or how high your temperature may run, if you are not distinctly sore on firm pressure down in this right lower or southwest quadrant of the abdomen,-but be careful not to press too hard, it isn’t safe,-you may feel fairly sure that you haven’t got appendicitis. If you are, you may still not have it, but you’d better send for the doctor, to be sure.