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on the diagnosis of appendicitis, I attempted incident- ally to treasure chamber slot machine lay down certain rules for guidance, with the view of simplifying the methods of reasoning in given cases, based upon the relation of the leading symptoms to pathological conditions. Since then a more extended experience has in the main confirmed the reliability of most of these observations, and mod- ified or qualified that of others. Taking the judiciously conservative ground to oper- 1 Paper read before the Practitioners' Society of New York, November 6, 1896. ate or not to operate as the occasion demands, we may appeal treasure chamber online impartially to the common sense of the general practitioner, who is usually the first to advise in the premises. He is always prompt in making his diagnosis, but not equally so in appreciating the ele- ments in the danger of delay, which a more careful watching of the case may avert. In private practice the responsibility of advising any operation is always attended with difficulty when the reasons for such a course are not well fixed. In remote districts expert surgical advice is not always readily obtainable, save at considerable expense, and the country practitioner, especially, is oftentimes in doubt as to the expediency of suggesting surgical consultation in what may prove to be a simple and uncomplicated case. The latter are numerous and frequent enough to deserve calm con- sideration. They demonstrate in the practice of every one that there is such a thing as safe conservatism, and that patients recover without operation and re- main perfectly well for long and indefinite periods. Thus, while every case should be watched and studied for dangerous symptoms, there is something else to be thought of than an immediate operation. As a proper starting-point for the consideration of the particular subject of these remarks, it may be said that what localized pain is to a diagnosis, so is the increased pulse rate to operation. Of all the symp- toms indicating danger that of the condition of the pulse is the most important. This is by no means a new observation, but one which is either not suffi- ciently enforced or not properly appreciated. I have been led to believe, from personal observation in a goodly number of cases, operative and otherwise, that this is the main and oftentimes the only guide to oper- ative interference. Other signs may be wanting, but this seldom fails. A " snappy" inflammatory pulse, continuously accelerated or increasing in frequency, is almost always an indication for operation. This al- ways shows an actively progressive pathological con- dition. The next important consideration is that of the character, localization, and persistence or increase of pain. Localized pain at McBurney's point, although an essential element for diagnosis, is of secondary ac- count as compared with the pulse in estimating the indications for operation. While it should always be treasure chamber slots free play present to a treasure chamber slot games greater or less degree treasure chamber slot in all cases, its pro- gressive intensity, which means so much, is not always manifest, even in the worst cases. Usually, however, the two essential elements of the pain symptom, with distinct localization and progressive intensity, corres- spond with the increase of frequency of the pulse. The sudden increase of pain is an indication of serious mischief, and u hen present outweighs that of mere tem- perature elevation in the argument for immediate op- eration. It is a leading symptom in perforation, in the so-called fulminating cases, and, save in exceptional cases, is always attended with symptoms of severe shock, usually with preliminary chill and generally with rapidly increased temperature. The temperature in appendicitis is never very high ; as a rule, the average is about 102° F. Without the symptoms previously stated, there may be a reasonable doubt as to the correctness of a diagnosis. By itself, MEDICAL RECORD. [January 9, [897 then, it means very little in our present estimate, but, associated with the other phenomena named, it makes assurance doubly sure. In fact, the increase of the three elements in the order of their importance, pulse rate first, pain second, and temperature last, constitute the cardinal indications for operation in every case; and, contrariwise, a decrease along the same lines, but more especially in the pain and pulse rate, means judi- cious waiting and safe conservatism. The actual number of pulse beats is not of so much account as their tendency to increase, although the rule of Willy Meyer, to operate when they reach from 116 to 120, is generally a trustworthy one, as I have proved in many instances. While I desire to emphasize these points as the really essential ones upon which quite positive opin- ions may be based, we are not to lose sight of inciden- tal circumstances which may be considered in the way of corroborating or of modifying final conclusions. Aside from the symptoms already mentioned, the gen- eral gravity of a case has a direct relation to severity and suddenness of the attack, but more particularly to the associated condition of prostration of the patient. He has what is graphically called " a very sick look" — always an ominous and anxious symptom, and almost invariably accompanying one or more of the cardinal signs of danger. In the foregoing resume we have taken into account only those symptoms usually noticed in the majority of cases which from the very nature of the disease re- quire careful study and accurate interpretation. Just here it may be stated that there is usually no necessity for hurry in arriving at conclusions. Ex- cept in the fulminating cases there is always oppor- tunity offered for noting the course of the disease. The initiative symptoms are generally very pronounced and exaggerated. A snap diagnosis is always unsafe under the circumstances. After the explosion of the primary attack there is a comparative retrogressive lull, and then comes at the end of from twenty-four to thirty-six hours, or longer, the important time for the study of what can then be demonstrated as the progres- sive signs of trouble. The fulminating cases, however, in which immedi- ate perforation occurs, admit of no argument as to the necessity of prompt and radical measures. Nor is there any danger of misunderstanding the significance of their symptoms. The sudden agonizing pain, first localized and then becoming general, the rapid thready pulse, the pinched face, hurried grunting respiration, increased temperature, and abdominal distention leave no doubt in the mind of the most casual observer. In the majority of these cases the increase of the pulse rate often anticipates that of pain and temperature. While every one knows that all cases of appendi- citis require the most constant and careful watching until actual recovery takes place, that we are never out of danger until all symptoms of the disease have dis- appeared, it is also true that there is no necessity ol becoming alarmed without cause, or becoming acces- sory to the patient's death by an overanxiety to oper- ate. It is with the view of enabling the practitioner to take a common-sense view of the question that this effort to formulate certain rules is attempted, in the hope that by being forewarned he can be safely ready and lie the better qualified to study indications with becoming calmness, and not be forced into unwarrant- able exploratory operations against the dictates of his better judgment. This may sound like a surgical her- esy, but we must admit, nevertheless, that we can al- ways afford to wait for emergencies rather than be 1 eager to anticipate what may never happen. I cannot help believing that, with a laudable at-

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