Acute appendicitis: A comparative survey with remarks on its management☆

Abstract Certain conclusions may be drawn from this mass of information. 1. 1. The operative mortality for acute appendicitis at this hospital, under a regime of radical treatment as practiced by a sizeable group of surgeons employing varied techniques, was 4.2 per cent during the year 1934–1935. This represents a marked reduction in the mortality of five years previously. While this mortality in no sense is comparable to that reported by certain clinics, better hospitals, and in various individual series, it nevertheless represents a rather respectable effort to cope with a problem of increasing difficulty. 2. 2. Inadequate hospital records prevented an evaluation of the importance which the factors of time and cathartics may have played in effecting this lowered mortality, but it is certain that better surgical judgment and improved surgery were largely instrumental in producing the marked drop in mortality which occurred in the group of cases complicated by peritonitis. 3. 3. The mortality in acute uncomplicated appendicitis at this institution is creditable and probably almost irreducible, but the treatment of appendicitis with abscess still shows a mortality which is much too high. 4. 4. A short experience with bacteriophage as an adjuvant in the treatment of ruptured appendicitis is reported. No apology is made for the brevity of the series since the cases are considered to be representative. However, it is appreciated that only through triai in a reasonably long series of cases can a true estimate of its value be reached. It is likely that no one operative procedure will effect a very material drop in mortality among the severe cases of appendicitis. Improved mortality in all probability will result largely from the exercise of better judgment as to when to operate and how much to do. However, three points in operative procedure do stand out as worthy of particular consideration in any plan for reducing operative mortality in appendicitis. 1. 1. The weight of evidence seems to indicate that in the very small percentage of cases where a severe spreading peritonitis complicates the picture, a regime of conservative treatment and temporary delay in operation offers the patient the best chance of.recovery. 2. 2. Controlled series seem to show that the use of the McBurney incision or its modifications favors a lowered mortality by confining operative manipulations to a very limited area of the abdomen, thus helping to keep the peritoneal infection localized. 3. 3. In an admittedly short series of cases, bacteriophage has shown that it is worthy of further investigation in the treatment of cases complicated by peritonitis. The experience has been that improvement in the hospital management of acute appendicitis is capable of producing a marked lowering in the mortality rate of this disease. It appears probable, however, that any considerable mortality drop will occur only when the public is thoroughly enlightened regarding the dangers of catharsis and of procrastination in the treatment of abdominal pain, and when routine early hospitalization of these cases will make possible removal of the appendix at a time when the operation carries with it, in experienced hands, a mortality which is almost negligible.