Columbia (Btttoetsitp mtfjeCttpofltftigork College of pfjpgtciana anb burgeons lifcrarp Gipt op RHODE ISLAND MEDICALSOCIE TY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/hassurgicaltreatOOvale Fiske Fund Prize Dissertation. No. LI. Has Surgical Treatment Lessened THE Mortality from Appendicitis? MOTTO : " Calyatatantravid." BY FKANK P. VALE, M. D., Washington, D. C. PROVIDENCE: Snow & Farnham Company, Printers. 1908. THE Trustees of the Fiske Fund, at the annual meeting of the Rhode Island Medical Society, held at Providence, May 28, 1908, announced that they had awarded a premium of two hundred ($200) to an essay on "Has Surgical Treatment Lessened the Mortality from Appendicitis?' 1 bearing the motto: " CalyatatantraTid." The author was found to be FRANK P. VALE, M. D., of Washington, D. C. DR. FRANK B. FULLER, Providence, DR. EUGENE KINGMAN, DR. A. A. MANN, Central Falls. Trustees. HALSEY DeWOLF, M. D., Providence, Secretary of the Trustees. Has Surgical Treatment Lessened the Mor- tality from Appendicitis? INTRODUCTORY. Iisr discussing with Dr his essay on , which was awarded the Fiske prize for . . . ., he called my attention to the above theme propounded by the trustees of the prize for 1908. The stamp of approval given by custom is such, one is almost astonished at the question ; it seemed so difficult to answer with in- dubitable evidence — however great one's confidence in the surgical treatment of appendicitis — I dismissed it from my mind ; it recurred, nevertheless, and some of the associated ideas brought the desire for an an- swer, if one is now possible. A large part of the operating seen in our surgical clinics is on the vermiform appendix ; this impression is abundantly confirmed by the compilations I have made from available hospital reports, showing that in the United States, since the year 1890, of 239,986 major and minor operations performed in 23 hospitals, no less than 26,044, or 10.8%, were on account of this useless appendage of the digestive tract. It is difficult to conceive that all this work represents misdirected en- ergy, from the standpoint of mortality ; yet some believe 6 HAS SURGICAL TREATMENT LESSENED there is much unnecessary operating in every depart- ment of surgery, that in a way the ability to operate recently acquired through anesthesia and asepsis, has conferred a license to operate ; is it possible we are now on the crest of a wave of enthusiasm for operative surgery, which will in time subside to a more stable level ? Reflection reminds us that the history of the advance of medicine has been over enthusiasm in first one direction and then another, followed by the inev- itable reaction. We please our vanity with the expres- sion " modern," as did our predecessors of one hundred years ago in bleeding for every disease, and those of fifty years later in transfusing almost as indiscrimi- nately. We need surgeons and true specialists to blaze new trails. Restriction of one's field of endeavor makes one expert, but may narrow the horizon : " La ten- dance a la specialisation s'est accrue, dans ces dernieres annees, d'une maniere inquietant pour la securite du public, et le titre de specialiste, loin de consacrer une superiorite, est arrive a. n'etre bien souvent qu'un brevet d'ignorance. Combien de docteurs en effect? en renongant a la medicine generale, ne cherchent autre chose dans une specialite, qu'un champ d' etudes plus facile et mieux remuneree." (Doyen [2].) Doyen and other surgeons, one a teacher of surgical pathology (3), believe that among the many and in- creasing requirements, every surgeon in the future will be his own pathologist: may not every physician, i. e., THE MOKTALITY FROM APPENDICITIS ? 7 'every pathologist, be in large part his own surgeon ? Certainly if operative work continues to increase as it has in the past twenty-live years, and if, for example, every case of appendicitis is to be operated as soon as the diagnosis is established, with a continued increase in this disease,* such would in time be a natural result. It is immaterial whether surgery absorbs medicine or vice versa, their divorce of past centuries is being nul- lified, as shown for instance in the latest sub-specialty, the '-Operating neurologist" (1). The subject before us, the treatment of appendicitis in certain of its as- pects, illustrates an advantage which would accrue from the more perfect union of physician and surgeon : the latter recommends immediate or early operation because of its relative simplicity and avoidance of dreaded complications with which his art is unable to cope ; the physician rejects immediate and routine operation because of the many recoveries in his expe- rience under medical care — in too long delaying early operation he may, however, evidence lack of apprecia- tion of the surgical opportunity. It has been said that in this day every physician must think surgically, but it is equally obvious every surgeon should be first and foremost a good physician. There must be found some point of vantage from which medicine can be viewed as a whole ; if specialism develops without such means * Toft's post-mortem findings, every third subject showing evidence of present or past inflammation in the vermiform appendix, with actual ulceration in 5%, indi cates a possible limit. Quoted by Fitz. 8 HAS SURGICAL TREATMENT LESSENED for its assimilation one hundred years from now a corps of specialists will hover over each patient. The liter- ature of medicine is rapidly becoming difficult to digest in any particular branch, not to speak of its entirety. Since 1896 there are indexed in the Catalogue of the Surgeon General's Library at Washington 295 mono- graphs, including graduating theses, and 3,616 journal articles on the subject of perityphlitis or appendici- tis, as compared with 20 monographs and 200 journal articles before that date. In 52 hospitals in this country with a total of 1,075,- 860 patients from 1890 to 1907, the proportion of cases of appendicitis was 1 in 47 before 1900 and 1 in 11 since (Tables IY and V) ; in 5 European hospitals with a total of 776,069 patients for the same period the pro- portion was 1 in 147 and 1 in 68 ; in 7 European hos- pitals with a total of 1,301,878 patients from 1870 to 1890 the proportion of cases of perityphlitis was 1 in 678 (Table I). Table VII shows the increase in mor- tality from appendicitis and decrease in that from peri- tonitis in this country, England and Wales ; the in- crease in the former in Paris; in Uruguay the increase in the mortality of appendicitis is accompanied by a slight increase in that from peritonitis, but a marked decrease from diseases of the stomach. Villaret (4) has compiled statistics from the army records of the War Department at Berlin, from which he concludes the increase in appendicitis is only apparent and due to our increased diagnostic ability which now correctly traces THE MORTALITY FROM APPENDICITIS ? 9 'various abdominal lesions and symptoms to the vermi- form appendix ; cases formerly described under the head of affections of the liver, peritonitis, gastralgia, ulcer of the stomach, gastric hemorrhage and chronic gastric catarrh were found to have decreased, per thou- sand, from 4.27 in 1873-4 to .95 in 1900-1, with a cor- responding increase in cases of perityphlitis from .52 to 1.73 — that is in twenty-seven years a decrease of 79% in the first group, balancing an increase of 70% in cases of perityphlitis. As having a possible bearing on this subject I was much interested to learn recently from Dr , who has devoted the past four years to the study of psy- chotherapy in various European clinics, the last year of which was in Paris at the Salpetriere with M. De- jerine, that the successors of Charcot now know the innumerable symptoms ascribed to hysteria, concern- ing which so many tomes have been written, were simply the result of their own, the physician's, sugges- tion. Is it possible there is a psychological side also to organic disease ? Heppe (5) has ascertained that the physicians of Berlin regard appendicitis more and more as a " Volkskrankheit," and would no longer feed lay curiosity with medical information.* A universal de- sire for knowledge of the psychological side of medi- cine is just being awakened; in its broadest sense it is the study of the microcosm — may here lie the van- *See an amusing squib by " Spectator," a Paris correspondent in the Boston Medical and Surgical Journal, March 19, 1908, p. 397. 10 HAS SURGICAL TREATMENT LESSENED tage-ground from which will spring a new era, unify- ing medicine and supplementing the tedious study of minutiae in anatomical and physiological investigation ? HISTORICAL. Nearly a quarter of a century has elapsed since the paper read by Dr. Reginald Fitz, of Boston, before the Association of American Physicians in 1886 (6), inaugurated the present operative era in the treatment of perityphlitis, or appendicitis as he termed it to bet- ter indicate what he regarded the actual seat of the disease — an idea which had been growing among med- ical men since 1882 (7), but crystalized and emphasized for the first time in this paper : It is a notable exam- ple of a physician's ability to indicate possible lines for surgical progress. In 1867 Dr. Willard Parker (8), one of the leading surgeons of New York, in a paper entitled " An opera- tion for abscess of the appendix vermiformis caeci," advocated timely incision, neither too early nor too late — " Not before adhesions had fully formed nor after a short period before the maximum formation of pus had been reached, that is from the fifth to the twelfth day." He noted the obscurity in which the pathology of the vermiform appendix was involved, the absence of its mention in ancient literature, and the fact that often only at autopsy is this cause of death recognized — gangrene and perforation of the appendix THE MORTALITY FROM APPENDICITIS ? 11 producing, especially in children a rapidly fatal result, with violent symptoms of peritonitis ; in adults, how- ever, " abscess of the appendix " being slower in its progress was easier to recognize — pain soon circum- scribing itself in the right iliac fossa, with a small tumor in that region ; if an abscess was maturing the external opening would tend to make it point in a safe direction — even in the absence of pus a free incision relieved tension without prejudicing the patient's safety ; if no adhesions formed to wall off the abscess, death resulted in two to five days — obviously in these cases surgery can be of no avail." Dr. Parker however had been in part anticipated in this recommendation as to surgical treatment about twenty years by an English surgeon. At a session of the Medical Society of London, Sept. 25, 1848, its pres- ident, Mr. Hancock, reported a case of " Disease of the appendix caeci cured by operation " which he believed was the first one of its kind : abscess of the abdomen connected with the caecum or large intestine, and at- tended with fluctuation had from time to time been opened, but this unequivocal sign should not be awaited, as the patient might die before the disease progressed thus far. He had simply suspected mischief about the caecum, or its appendix, and incised a cord like induration close to the spine of the ileum ; at the end of three weeks a faecal concretion was discharged which from its size he imagined had been impacted in, and escaped by ulceration from, the appendix vermi- 12 HAS SURGICAL TREATMENT LESSENED formis. " In some remarks upon this case Mr. Hancock referred to the frequency of operations on the abdo- men of late, particularly in case of ovarian disease, many of which had been successful. He should not argue or draw conclusions from a solitary case, but he thought it, at all events, would justify us in having recourse to such a procedure in cases of peritonitis, when all other means had failed, and without which death was inevitable." Dr. Copeland said he had writ- ten on the subject sixteen years before; and he com- plimented the author on the only successful case he had ever heard of (9). Mr. Dendy remarked that in doubtful cases the exploring needle should be used, a practice advocated and followed forty years later in in this country by Dr. William T. Bull. The earliest reports of the disease,* aside from iso- lated references, are from the wards of the Hotel-Dieu, Paris, first from the medical side and afterwards from Dupuytren's service. It was probably, in part, the passive attitude of this leading spirit in the surgical world toward these " engorgemens inflammatoire dans la fosse iliaque droite " which exercised a deterrent effect on operative intervention for the next half cen- tury. Five of Dupuytren's six cases recovered through spontaneous rupture of the abscess — one emptying * This statement must be amended with great credit to Mellier for publication the same year (1827) of seven cases, all terminating fatally, with autopsy on each case showing a gangrenous vermiform appendix which was regarded as the starting point of the pathological changes in the abdomen. — (Jour. Gen. de Med. 1827 xxxix de la lie Serie.) THE MORTALITY FROM APPENDICITIS ? 13 into the bowel, which he regarded as rather a favor- able circumstance (11) ; of the fifteen cases of Hnsson and Dance only ten can be accepted, and one of these is also reported by Dupuytren (their seventh case is his first) — leaving nine cases with eight recoveries, four with spontaneous rupture of an abscess, and four without external evidence of suppuration, a total of thirteen recoveries and two deaths. One of the most important papers of this early period is by Grisolle (13), also at one time Chef de Clinique at the Hotel Dieu; he advised, however, in- cision of the abscess as soon as there was fluctuation, and did not regard it as prudent " de demurer simple spectateur des efforts de la nature .... c'est ce qu'avaient tres bien compris les chirurgiens du dernier sciecle qui, des qu'ils avaient soupconne la presence du pus, etaient vivement preoccupes jusqu'a ce qu'ils eus- sent evacuee ce produit morbide." His prognostic figures — 20 deaths in 73 cases — are quoted as late as 1883(14). "En generale, le prognostic n'acquiert de la gravite que lorsque le phlegnon a passe a l'etat de sup- puration. II faut neanmoins se rappeler ces cas rares, il est vrai, ou Ton voit la phlegmasie du tissu cellulaire s'etendre rapidement au peritoine, avant que le pus soit forme ou lorsqu'il n'est encore qu'infiltre." Though Rokitansky (15) had studied the anatomical side of the subject Puchelt (16), professor of medicine at Heidelberg, was the first German to take up its clin- ical aspects, suggesting the term perityphlitis. He 14 HAS SURGICAL TREATMENT LESSENED described also a primary inflammation of the vermi- form appendix, resulting in ulceration, perforation and gangrene of the appendix and of the intestines . and neighboring muscles, with the formation of an extenal stercoral abscess or the escape of fecal matter into the peritoneal cavity. The first book appeared in 1846 : " Die durch Koth- steine bedingte Durchbohrung des Wurmfortsatzes, die haufig verkannte Ursache einer gef'ahrlichen Peritoni- tis, und deren Behandlung mit Opium : von Adolph Volz." Herein we find a list of thirty-nine fatal cases of peritonitis, most of them treated with calomel and other laxatives, ten of them the author's observations, and the others from the literature, all of which upon post mortem examination revealed pathological changes in the vermiform appendix ; and in contrast a further list of fourteen recoveries, with the exception of two, all being treated with large doses of opium j but four of them are eliminated by the author, as of doubtful origin in the appendix. Thus the monograph sets forth the value of opium in peritonitis following perfo- rative appendicitis ; only one previous case had been reported, in France, by Petrequin (17) ; its use origi- nated with Graves of Dublin about 1824, who success- fully treated two cases of peritonitis following para- centesis ; and was later employed by his friend Stokes (18), in one of whose patients the peritonitis entirely subsided with the opium treatment, only to relapse on the administration of a mild laxative with a fatal re- THE MORTALITY FROM APPENDICITIS? 15 suit, post-mortem examination showing a perforated caecum with the intestines in the right iliac fossa agglu- tinated. The part played by opium since then, and the sentiment gradually raised against it, is well known. In 176 fatal cases of perforating appendicitis Fitz found in 60 death had occurred in the first five days, consequently the earliest day set by Parker for incision was too late to afford the possibility of relief in more than one-fourth of all, and " if the indications for ope- ration justified the election of a day as early as the fifth, they still more justified the choice of the third day," before the encysted or circumscribed peritonitis became general and death inevitable. His conclusions were that the early recognition of perforative appen- dicitis, in most cases comparatively easy, was of vital importance : urgent symptoms should be met by imme- diate laparotomy and extirpation of the perforated appendix after recovery from the accompanying shock. If delay was warranted, the resulting abscess should be iucised when evident, usually by the third day. He made no attempt to consider in his paper the process until there was evidence perforation had taken place, because of the obscurity of the signs of the incipiency of the inflammation. By the comparison of the sym- toms of 209 cases of perityphlitis with 257 cases of perforative appendicitis, he had shown them to be sim- ply different aspects of one and the same inflammatory process, beginning in the appendix. 16 HAS SURGICAL TREATMENT LESSENED American surgeons soon began to record their expe- riences. Morten's (19) seems to have been the first; he saw the patient two days after symptoms of perfora- tion ; the unsuccessful laparotomy was recommended as offering the best hope of recovery. Sand's (20) first successful case was not an appendicectomy — neither the appendix nor the lips of the perforation at its base, from which two fecal concretions escaped, were gan- grenous ; the edges of the perforation were simply trimmed and brought together with three silk sutures. The first series of six cases was reported by Weir (21) — all fatal. Then followed McBurney's (22) more en- couraging series of 11 cases with only one death, all operated within the first 48 hours; and two years later (23) his additional 13 cases, without a death, making 24 with one death to January, 1891. In McBurney's second paper indications for early operation was clearly stated, and so well stated practically nothing essential has been added since. He would not operate on all cases on the first day to anticipate danger. In the previous year he had seen himself 13 cases so mild no one would have thought of recommending an opera- tion ; if tenderness was not increasing, temperature not over 100 and pulse but little accelerated, recovery could be anticipated; but by the end of 36 hours from the beginning of the attack — often earlier with the case progressing badly — if the symptoms were becom- ing worse he would operate. THE MORTALITY FROM APPENDICITIS? 17 / The pendulum swung to the extreme with the claim of some surgeons that the only proper treatment of appendicitis is immediate excision of the appendix ; this Fitz (24) thought was going too far. In 1900 he reported (25) the cases he had seen in the previous four years, 72 with 19 deaths, the largest series re- corded up to that time, about half of which had been operated with a mortality of 40%, and a mortality of 11% for those not operated. Deaver (26) was one of the first to recommend immediate operation, and has since been one of the strongest supporters of this con- tention. In a discussion of a paper by Richardson read before the Association of American Surgeons in 1899 (27) he urged operation on all patients except those in collapse and with active general peritonitis. The following were some of the remarks of Senn, ex- pressing his own opinion on this point : " Any surgeon who follows such a stringent rule, with few exceptions, as advocated by Dr. Deaver to-day may be a good practitioner, but he would make a poor and dangerous teacher I do not wish to insinuate against Dr. Deaver, who certainly stands at the head of the surgical profession of this country, and whose practice is perfectly safe in abdominal work, but I do know from personal knowledge, of men who have been guided by the rule he lays down, who have repeatedly removed the healthy appendix For my part I always feel weakest in the matter of making an early 2 18 HAS SURGICAL TREATMENT LESSENED diagnosis in the first attack." Deaver says however : " Better take out a healthy appendix and have the patient recover, than a diseased one and have the patient die" (27). Abroad, Biedel is the- leading advo- cate of immediate operation in all cases (28). Since the paper of Fitz the disease has been claimed for treatment by the surgeon, not only in this country but abroad. " Sonnenburg hat den Satz ausgesprochen : Die Perityphilitiden gehoren den Chirurgen. Gut ! Gehen wir darauf ein, machen wir den Versuch ! " (Sahli, 1895 (29) ). STATISTICS. In an effort to ascertain the effect of surgical treat- ment on the mortality of appendicitis there are three sources from which to gather data : reports of individ- uals, reports of hospitals, and reports of the Public Services — Army, Navy, and Marine Hospital Service.* The words mortality and fatality are generally em- ployed synonomously, but the former may be restricted to frequency of death per unit of population and the latter per unit of sick. Mortality statistics are com- piled by governments from certificates of death fur- nished by physicians; with a given fatality, the mor- tality of a disease will vary with the morbidity. Fatal- ity is an index of the success of treatment, two impor- *An effort to secure data abroad, through United States Consuls in the large cap- itals of Europe, was unsuccessful. THE MORTALITY FROM APPENDICITIS? 19 tant factors being the severity of the disease and the resisting powers of the patient. Morbidity is in- fluenced by endemic, epidemic and psychological fac- tors, concerning which we have but meagre informa- tion. The first large series of cases of perityphlitis was compiled by Mattersock in 1880 (30), 977 attacks with 294 deaths, or 30% ; since then this has been gener- ally accepted as the fatality previous to the present operative era in the treatment of appendicitis, or peri- typhlitis as it is still called by most European writers.* Mattersock's data is not given in detail; as it includes the earliest period in the history of the disease, it seemed possible this fatality was unduly high from in- clusion of inflammatory processes in the iliac fossa fol- . lowing accouchment, as in Grisolle's 20 deaths in 75 cases of " tumeurs phlegmoneuses des fosses iliaques," the latter in fact stating their fatality was about twice that of the non-puerpereal. I have collected from the reports of all the European hospitals accessible, seven in number, 1,916 cases of typhlitis and perityphlitis with 128 deaths, or 6.6%, for the period 1870 to 1890, previous to which the number of cases rapidly dwindles, just as appendicitis disappears from American hospital reports about 1890. There are chiefly two classes of cases of appendicitis *"The mortality is not by any means clearly established." (Fitz, N. Y. Med. Jour., May 12, 1888, p. 505.) Noyes collected 100 cases treated by simple incision of the abscess with 15 deaths. (Trans. R. I. Med. Soc, 1882-3, p. 495.) 20 HAS SURGICAL TREATMENT LESSENED not included in reports of perityphlitis from 1870 to about 1890 — general peritonitis starting in the appen- dix and those described as chronic. To ascertain their relative frequence I have collected from all the reports of American hospitals accessible, in which this infor- mation is given, seven in number (Table II), 13,894 cases of appendicitis, of which 664, or 4.7%, were com- plicated by general peritonitis, and 5,211, or 37.5%, were chronic. Table III shows how little the fatality of 6.6% is changed by "correcting" the statistics for the twenty years preceding 1890, by means of the in- formation just stated, in an effort to make the periods before and after 1890 comparable — the large number of mild cases with a negligible fatality offsetting the small number with a high fatality. The statistics of Sahli immediately following 1890, and those of Strieker ending in 1905, in their correspondence with the figures I have given for the period immediately preced- ing 1890 ; suggest more than a coincidence. Sahli (29) in 1895 collected 7,213 cases with 692 deaths, or 9.7%. from reports made to him by 466 phy- sicians — 475 attacks, or 6.5%, were subjected to ope- rative interference. The deaths were 101 of those operated, or 21% ; and 591, or 8.8%, for the 6,740 treated without operation. Strieker (31) in 1906 collected a still larger series of cases from the records of twenty corps of the German Army : THE MORTALITY FROM APPENDICITIS ? 21 Cases. Died. Operated. Died. Treated Without Operation. Cases. Died. 1880 to 1900. 6,296 4,498 270 (4.2%) 142 (3.1%) 235 (3.7%) 629 (14%) 66 (28%) 98 (15.5%) 6,061 3,869 204 (3.3%) 44 (1.1%) Total 10,794 412 (3.8%) 864 ( 8%) 164 (18%) 9,930 248 (2.5%) Combining the statistics of Sahli and Strieker, which agree significantly, we have a total of 18,007 cases with 1,104 deaths, or 6.1% ; 1,337," or 7.4%, subjected to operation; the deaths were 265 of those operated, or 19%, and 839, or 5%, for the 16,570 cases, or, better, attacks treated without operation. From the Public Services, in this country, I have collected (Table XI) 3,347 attacks of appendicitis since 1895, with 160 deaths, or 4.7%. It must be noted more than half were operated, as compared with 14% operated in the German Army — and practically the same fatality. I have collected from the reports of 52 hospitals, in this country, 43,039 attacks of appendicitis treated since 1890, with 3,152 deaths, or 7.3%; the fatality before 1900 was 11.3%, and 6.3% since. From the reports of 23 of these hospitals (Table IV), it was pos- sible to ascertain the number subjected to operation — 28,036 attacks with 26,044 operated, or 92%, of which 22 HAS SURGICAL TREATMENT LESSENED 5,210 attacks were before 1900 with a fatality of 11.7% operation in 81%, and 2-2,826 attacks since 1900, with a fatality of 5.9%, operation in 95% ; the remaining 29 hospitals (Table IV) undoubtedly agree closely with this group in the percentage of cases sub- jected to operation. From the reports of 5 European hospitals (Table VI), unfortunately all that were acces- sible, I have collected an additional 7,589 attacks since 1890 ; for 971 of these, treated at the Charite, Berlin, with 66 deaths, or 6.7%,- the number operated cannot be stated, though 302, or 31%, are found in the re- ports of the surgical division; of the remaining 6,618 attacks with 872 deaths, or 13.1%, there was operated 3,469, or 52%, making a total of 34,654 attacks with 2,832 deaths, or 8.1%, from reports of American and European hospitals in which the proportion subjected to operation can be stated, namely, 85%. In Table IV it can be noted there is a decrease in fatality for each hospital since 1900, and an increase in the per- centage of cases operated, but on scrutiny of the ex- tracts from the hospital reports, which follow, one finds in some instances this is due to an increase in the chronic, interval, subacute and less serious cases. The history of the operation in this country and England seems epitomized in the list of operations performed at Roosevelt Hospital, New York — where Dr. McBur- ney was the Surgeon in Chief until 1900 — and at St. Bartholomew's, London (Tables VIII and IX). THE MORTALITY FROM APPENDICITIS ? 23 Since 1900 there have been treated in three hospitals in this country — St. Mary's, Rochester, Minn., The German, Philadelphia, and The Augustana, Chicago, representing the work of Drs. William J. Mayo, John B. Deaver and A. J. Ochsner — 10,247 cases, 97% being subjected to operation, with 351 deaths, or 3.4%: 4,173 of these, or 40%, are described in the reports as chronic or interval cases, with only 11 deaths, or 0.2%, deducting which there remains 5,141 acute and sub-acute cases with 302 deaths, or 5.8% (Table X). This agrees closely with 1,180 cases treated by Riedel (28b) in Germany, between January 1, 1903, and September 30, 1907, with 76 deaths, or 6.4%. Ridel's most fortunate series of 441 cases with 12 deaths, or 2.9%, subjected to operation between Jan- uary 1, 1906, and September 30, 1907— excluding 130 cases in children with 13% fatality — andMayo's 1,957 acute cases with 47 deaths, or 2.4%, for the eight years 1,900-07, excluding 2,287 chronic cases with only 2 deaths, or 0.08%, can be regarded as the present high- water mark of surgical success in the operative treat- ment of, acute appendicitis, all cases being subjected to operation. If Mayo's acute and chronic cases are com- bined they make a unique series of 4,784 cases since 1900, with a fatality of 1.0%, all but 19 with 5 deaths being operated. To compare with it there is Strieker's unique series of 3,869 cases for the six years, 1900-05, treated without operation, with a fatality of 1.1%. There are no medical statistics showing the fatality of 24 HAS SURGICAL TREATMENT LESSENED "chronic" cases. I have collected 10,798 chronic and interval cases subjected to operation, with a fatality of 0.5% (Table X). SUMMARY. I have collected in all 55,891 attacks of appendicitis with 4,378 deaths, or 7.7% : 1,916 with a fatality of 6.6% treated in the preoperative era, before 1890, and 53,975 since, with a fatality of 7.8%, from 50% to 100% being subjected to operation in different series of attacks constituting this total. The combined sta- tistics of Sahli and Strieker give 18,007 attacks with a fatality of 6.1% — the number subjected to operation being only 7.4%. It must be remembered, however, that to compare a series of cases with recurrent at- tacks, treated by purely medical means, with a series in which all are operated, and therefore without recur- rent attacks, the fatality in the former should be in- creased by the percentage of recurrences ; when part are operated and part treated medically this difference is lessened. Because of insufficient data it is impos- sible to correct the statistics for this factor, but, for example, in 13,036 of the attacks reported by Sahli and Strieker there was recurrence in 19.8%, with the aid of which information the actual number of their cases, suffering 18,007 attacks, can be approximated at 14,440, increasing the fatality of 6.1% for the attacks, to 7.6% for the actual number of cases. There are no THE MORTALITY FROM APPENDICITIS V 25 statistics on a large scale showing the relative fatality of the primary attack and recurrences ; 78% of the recurrences, in Strieker's statistics, were within the first year and less than 10% after the second year. The surgeon assumes grave responsibilities in his efforts to aid nature, the consciousness of which must often weigh heavily upon him. Every one who desires to engage in surgical work, every one who is called upon to advise as to the necessity of surgical interven- tion, must determine for himself what constitutes legit- imate surgery. The subject of this essay placed on trial a large amount of operating ; the evidence accum- ulated can speak for itself. My own conclusion is that with the inauguration of the present operative era in the treatment of appendicitis, the fatality of the dis- ease was increased before 1900, and later subsided to about its point of departure — that is when the sum totals are considered. The success of any one operator points to what all may hope to accomplish, but such final and general success in the surgical treatment of appendicitis will have to be chronicled by some future essay. 26 HAS SURGICAL TREATMENT LESSENED REFERENCES. 1. dishing: Surgery, Gynecology and Obstetrics, March, 1908. 2. Doyen: Traite de Therapeutique Chirur^-icale et de Technique Operatoire, Paris, 1908. Vol. 1. 3. Bloodgood: Journal of the American Medical Association, Nov. 3, 1906, p. 1470. 4. Villaret: Deutsch. Med. Woch., Jan. 1, 1904; p. 16. 5. Heppe: Die Appendicitis in Kenton Aargau, besonders ihr endemisches Auftreten und epidemisches Aufflacken, 1906. 6. Fitz: Trans, of the Assn. of American Physicians, 1886. Vol. 1; p. 107. 7. Hawkins: Diseases of the Vermiform Appendix, London, 1895. And see for example Lancet, Dec. 19, 1885; p, 1166; also New Vork Med. Jour., January, 1881; p. 1. 8. Parker: Med. Eec. N. Y. Vol. II, 1867; p. 25. 9. Copeland: Dictionary of Medicine, London, 1858. Vol. 1; p. 278. 10. Bull: Med. Rec. N. Y., March 6, 1886; p. 265. 11. Dupuytren: Lecons Oral es de Clin. Chir., 1833. Vol. Ill; p. 330. 12. Husson et Dance: Repertoire Generates d 1 Anatomie et de Physiol, et de Clin. Chir., 1827. Vol. IV; p. 74. 13. Grisolle: Histoire des Tumerus Phlegmoneuse des Fosses Iliaques, Archiv. gen. de med. 3 Ser. Vol. IV, 1839; pp. 34, 137 and 293. 14. For example see Dantel: These de Paris, 1883, De la perityphli- tis primitive. 15. Rokitansky: Pathologische Anatomie, Wien, 1842. Vol. 3; p. 285. 16. Puchelt: Encyclopedie des Sciences Medicales, 1843. Vol. VI. THE MOETALITY FROM APPENDICITIS ? 27 17. Petrequin: Gaz. MeU, Paris, 1873. Vol. VIII; p. 438. 18. Stokes: Cyclopedia of Practical Medicine, of Forbes, Tweedie and Conolly. Vol. Ill; 1834. 19. Morten: (a) Proceedings of the Philadelphia County Med. Soc, 1887. Vol. VIII; p. 263. (b) Jour, of the Amer. Med. Assn., June 16, 1888. (c) Med. Bull., Phila., 1*02. Vol. XXIV; p. 212. 20. Sands: N. Y. Med. Rec, Feb. 25, 1888; p. 197. 21. Weir Med. News, April 27, 1889; 449. 22. McBurney: X. T. Med. Jour., Dec. 21, 1889; p. 667: "Early operative interference in cases of diseases of the vermiform appendix." 23. McBurney: Ann. of Surgery, 1891. Vol. 13; p. 232. 24. Fitz: Boston Med. & Surg. Jour., July 28, 1892; discussion of Worcester's paper. 25. Fitz: (a) Trans, of Assn. of Americ. Physic. Vol. V, 1890; p. 39. (b) Bost Med. & Surg. Jour., June 19, 1890; p. 505. 26. Deaver: Treatise on Appendicitis, 1st Edt., 1896. 27. Deaver: Phila. Med. Jour., July 5, 1902; p. 18. 28. Riedel: (a) Berl. Klin. Woch., August, 1899; p. 717. (b) Munc. Med. Wch., Nov. 26, 1907; p. 2565. 29. Sahli: Cor. Bl. f. Schweiz Aerzte, Sept. 15, 1895; p. 561. 30. Mattersock: Gerhard's Handbuch der Kinderkrankheite. Tii- bigen, 1880; p. 894. 31. Strieker : Die Blinddarmentzundung in der Armee vpn 1880-1900. Berlin, 1906. HAS SURGICAL TREATMENT LESSENED TABLE L Showing Cases of Perityphlitis and Typhlitis Recognized Between 1870 and 1390 in the Seven European Hospitals Named. Name of Hospital. To taV Patients. One in Cases. Died. Pr. ct. Charite, 1874-1889 : 241,030 207,111 533,813 116,526 49,994 105,679 (798) (1511) (658) (515) (442) (620) 302 137 811 226 113 170 14 10 57 4 12 22 128 4 6 K. K. Krankenanstelt Rudolph-Steffenig in Wien 1865-1891 7 P, Allgemeine Kran. Wien, 1868-1890 Kirkenhaus Wieden, 1868-1889 Middlesex Hospital, 1869-1889 St. Bartholomew's, 1873-1888 7. 1.7 10.6 13 9 1,301,878 (678) 1916 6.6 THE MORTALITY FROM APPENDICITIS ? 29 REPORTS OF CHARITE HOSPITAL. Berlin. 1874.... (I) 1875.... (II) 1876.... (Ill) 1878.... (IV) 1879.... (V) 1880.... (VI) 1881.... (VII) 1882.... (VIII) 1883 .... (IX) 1884..... (X) 1885. .. (XI) 1886.... (XII) 1887-88. (XIII) 1888-89. (XIV) Total No. of Patients. 13,792 14,149 12,378 15,125 16,618 18,234 18,225 18,009 17,463 16,862 18,335 18,263 23,269 20,358 241,030 Cases of Typhlitis and Peri- typhlitis. 16 Medical Report 11 » " 10 " " 12 " " 12 « 5 " " 17 " " 18 " " 20 " " Surgical Report 36 Medical Report 1 Surgical Report 39 Medical Report 1 Surgical Report 27 Medical Report 3 Surgical Report 50 Medical Report 3 Surgical Report 18 Medical Report 3 Surgical Report 302 Died. U (4.6%) 30 HAS SURGICAL TREATMENT LESSENED REPORTS OF K. K, KRANKENANSTALT, Rudolph- Steffenig in Wien. Teak. Total Number of Patients. Cases. Died. 1865 6,197 7,821 8 J 55 8,234 7,883 7,328 7,112 7.064 7,162 6,254 6,692 6,540 6,588 7,316 7,825 7,460 7,104 7,610 8,954 8,042 8.694 7,660 8,031 8,509 8,766 8,445 9,065 2 1 6 4 3 3 6 6 5 7 4 11 1 4 2 8 10 8 8 17 6 15 2 2 1 1 1 1 2 1866 1867 1868 1869 1870 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 207,111 (1 in 1511; 137 10 (7-2%) THE MORTALITY FROM APPENDICITIS ? 31 K. K. ALLGEMEINEN, Krankenhaus ztj Wien. Year. Total Number of Patients. Cases of Appendicitis. Died. 1868 20,880 21,977 21,657 22,860 24,007 22,049 20,563 21,297 20,659 21,743 22,263 23,068 23,249 23,565 23,981 24,759 25,689 24,448 24,397 25,796 25,138 25,473 24,285 12 12 21 22 25 38 32 25 20 31 27 31 36 22 35 45 54 30 32 58 72 65 66 o 1869 1870 1 1 1871 2 1872 3 1873 o 1874 1875 o 1876 1877 5 2 1878 1879 1880 5 2 1881 . 1882 1883 6 6 1884 2 1885 4 1886 1887 1888 3 2 1889 • 5 1890 o 533,813 (1 in 658) 811 57 32 HAS SURGICAL TREATMENT LESSENED REPORTS OF K. K. KRANKENHAUS, WlEDEN. Yeak. Total Numbek of Patients. Cases of Appendicitis. Died. 1868 7,820 7.105 6,344 7.563 6,481 3,406 3,468 3,204 3,167 3,182 3,413 3,208 3,873 4,046 4,084 4,261 6,955 6,732 7,189 8,095 6,564 6,366 2 1 5 13 10 13 5 7 3 6 8 3 11 7 10 13 22 38 12 17 20 20 1869 1870 1871 1872 1873 1874 1875 1876 1877 1 1878 1879 1880 1881 2 1882 1883 1884 1 1885 1886 1887 1888 1889 116,526 (1 in 515) 226 4 (1-7%) THE MORTALITY FROM APPENDICITIS ? 33 REPORTS OF MIDDLESEX HOSPITAL. 1869 1870 1871 1872, 1873 1874, 1875 1878, 1879 1880, 1881 1882 1883 1884 1885 1886 1888 1889 Total Number of Patients. 2,142 2,123 1,991 2,061 2,596 2,797 2,910 2,279 2 853 2,763 3,010 3,092 2,901 1,810 2,951 3,123 3,097 3,226 Cases of Typhlitis, Perityphli- tis AMD PERICAECAL ABSCESS. 4 Medical Report 4 1 4 12 4 7 5 10 8 16 8 1 Surgical Report (Ulceration and perforation of vermiform appendix.) 2 Surgical Report (Pericaecal Abscess) . . . 14 Medical Report 3 Surgical Report 8 Medical Report 3 Surgical Report ........ 9 Medical Report 1 Surgical Report 15 Medical Report 6 Surgical Report Died. 47,725 157 (1 in 303) 9 (6-7%) 34 HAS SURGICAL TREATMENT LESSENED REPORTS OF ST. BARTHOLOMEW'S HOSPITAL, London, Eng. Year. 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 Total Number of Patients. 5,902 6,342 6,057 5,623 5,225 5,653 6,314 6,529 6,896 7,383 7,397 7,640 7,349 6,908 7,529 6,932 Cases of Appendicitis. 6 5 1 2 5 2 3 2 16 15 10 16 10 6 12 26 Medical Report — Typhlitis Medical Report — Typhlitis and Coleritis Medical Report — Perityphlitis. . . — Typhlitis Perityphlitis , Typhlitis . . , Perityphlitis . Surgical Report : 2 Perityphlitis 4 Perityphlitic Abscess. Medical Report — Typhlitis .... 25 Medical Report: Typhlitis (4 died) 1 Surgical Report : Perityphlitis (1 died) 29 Medical Report : Typhlitis (3 died) 4 Surgical Report : Perityphlitis (0 died) Died. 105,679 (1 in 621) 170 22 (12.9%) THE MORTALITY FROM APPENDICITIS ? 35 REPORTS OF ST. THOMAS' HOSPITAL, London, Eng. Yeak. 1878 1879 1880, 1881, 1882, 1883, 1884 1885 1886 1887 1889, Total No. of Patients. 3,356 3,183 3,351 4,007 4,146 4,432 4,699 4,479 4,458 4,385 4,953 4,545 Cases of Appendicitis. 3 Medical Report 'J 44 44 5 Medical Report 1 " " Perforated. Appendix. . 16 ' : Report 8 " " Perforated. Appendix. . 13 " " 2 " " Perforated. Appendix. . 1 Surgical Report Typhlitis . . 12 Medical Report 4 " " Perforated. Appendix. . 17 « " 18 " "Perityphlitis 3 " " Perforated. . Appendix. . Died. Acute peritonitis, pleu- risy and pericarditis. 49,994 113 (1 in 442) 12 (10%) 36 HAS SURGICAL TREATMENT LESSENED TABLE II. Showing Proportion of Cases under head of Chronic Appendicitis and Appendicitis with General Peritonitis for Hospitals and Period Named. Name of Hospital and Years (included in). Massachusetts General, 1899-1906 St. Mary's, 1903-1907 Roosevelt, 1889-1906 St. Luke's, 1901-1907 J. Hood Wright, 1901-1907. . . . Augustana, 1900-1906 Rhodelsland Hospital, 1897-1907 Appendicitis with General Peritonitis. 255 (149 died) 38 ( 16 died) 112 ( 82 died) 66 ( 28 died) 34 ( 16 died) 82 ( 35 died) 77 ( 44 died) Chronic Appendicitis. 965 ( 2 died) 2,351 ( 1 died) 347 ( 3 died) 562 ( 2 died) 25 ( died) 785 ( 5 died) 176 ( 2 died) Total Cases. 3,035 3,955 1,912 1,348 363 2,175 1,106 664 (370 died) 5,211 (15 died) 13,894 (4.7%) (37.5%) (100%) THE MORTALITY FROM APPENDICITIS ? 37 TABLE III. Correcting Table I by Means of Information Furnished in Table II. Cases recognized as peri- typhlitis and typhlitis between years 1870- 1890 in seven European hospitals as shown in table 1906 or 57.8% Estimated number cases General Peritonitis. . . 156 or 4.7% Estimated No. Chronic Cases 1241 or 37.5% Estimated propor- tion of entire No. in view of table . Assumed fatality of 100% Died 94 (5%) Died 156 Estimated total number cases in view of table . . 3,313 100% 250 (7.5%) 38 HAS SURGICAL TREATMENT LESSENED W ►J M < * 2 2 3 ^ g O © «J fc S cm di o cd t~ cm x o 3 -* to r- — l* »-H cc cc cm to to to ^- >o rncr-e-f c:-.-:.-,r-7.^ r-. n cc cc o cm t © o -c* cs cm t- :c to to b- cc c^fc- OH-fOM cc^di o cm cm di to" iH"as"»-«Vr cm"^" — " '0061 u'; -t :i ^ x m [- r. t: -? co :. r. ■; -i r. ^ - o ^ f^ rJ ^ r I- I- I- I- r, - i. rr, Y 1.", — r. i — i i ~ JO TO .-< w is TO i- cc cc l- i-H tD ►-« io to cm -r PUB 006X - 1 — ' ~ ~ ~ c x cd : : - 1 1- to l~ cc c i :~ ^ cc cc -- ■ cd o-c* c- — l-lO •poua'^»-(lOCCCDCDXC>iQ6cDTOT-Mr'Oi-l--00^ •fBJOX ©tr-TOCOLDCCO-rCDC7CTOTO — OJC-t-f -tHn^CC © C M ffl rf O CO CD CN TO C p ID L- CC LC CD t}" Tj* i-H TP CM CM CM t-H i-l t-i "0061 e.iojag cc x : ice r ac : i - c: - :i '/. D t- o c o h ii o io ih o i-H <-l CM r-c CN ~. -j< -T CD CN i-C CM CM CO »-l CM pne 0061 Cl O " Cl CC t X o t C -< LC rt C C D DC TO CD TO CC IC CD ■3* TO CM CC Dl ■— TO *^* CD CC CC CD DI CO »D t- -c* --H i-C DC i-H DC1 •l^ox i a o : — — - ■ CC CO ^ co « h : i -i< c; -^ -t ^ h ri c h o co el : x c .-: :i h •- cr. i- t- cr. l- cc .— lc cr. cr. cc - co cc ■rP co C5_«* t—^t^ci •+ cd^co_cd_co t-H co t rH co'i-Ti-T t-T CM* o" ^-T '006T Pa'B 0061 •TOOX '006T ci o -}- 1- ci ci cc, l- ~ r; n lc h -m x c ^ x c rt o n C3 ^Nt-cMXa-f cci x -j: 1 1 — :c x cm- ci o th m l- cn oo rlH »-l H H *J IO n •* !M H N H CI uo cc lc re o ~ o — re l-; i— i-- :o ~h cc i£> -F cc t-< i_c ci tc ".j: co co oj c c. ^ :: r. : ! r. l- x c t- c] r- co -t x w c x uc m IC3 CN t- CN CC c^^I^-cOl-HCT;t-c^t^^--o^occt-- | C3cc-ro(^^CiO* ' e (MOr? CD CC C CN CO CD CN CI r- LC C-1 CC CO Tl i-H CN i-l CN » C5C5»-HCDL— CTi-^t— < ZZ CC IC-H-frTj CNCCCXJCDOiOlCr-CO co co cc cc r. c x :■: r. *x o :i •* h i- cr. ic io ~- o co th cd co^^th_c^l-^l^-^c: co t^ rc^LC_co__t-H__0__LC ^c -r ci ^rc^-^-H^ COHHWH — * P^i^ 0061 C. O H CI C M -t t- C X CM ri i- c c -t c ~ c: — - cc cc cc c -r :i -t h i^- ci i c co -t t- - x o uc i- c. c -f x x i- :ict-o c — .S^: g^:': *fe^s»; ^ co cc cs -Id; "H.^ 7s 4; t-^j _r' o - 2 n> "3 "S ■^ c« CD J5 g Pi 11? i! 1 CC! O r- -DC £ rn ffiffi g CS ID ^ >c S to § 2 1,1 - cS K >,* loo seisms 2' ■■_ ci"' r^.2 , !|z;>h o-a-i 2 °. J x^~ H *= S -^ — '3 C - ^ ~ u — e8'jP B illliSglll^|S2ila [zioijSjS; HCMTO-ctO-OCDt-COCCCDrtDITO-fLOCDt-CCCCCD— ' CM — 00^ IDJ^ dT i-T THE MORTALITY FROM APPENDICITIS ? 39 'TOOX •an90.i9 O 6 1 9 21 2 o O 4 7 4 2 4 12 35 67 68 59 251 14 172 1897 . 6 71 1898. . 4 89 1899 13 116 1900 6 104 1901 . 5 160 1902. . 7 174 1903. . 22 . . 147 1904 42 258 1905 1906 68 8 with general peritonitis, 4 died. 73 369 214 1907 1900 and after. Before 1900. 72 9 with general peritonitis, 4 died. 295 419 1,845 448 24 5,218 319 , 23 265 2,293 46 HAS SURGICAL TREATMENT LESSENED REPORT OF MASSACHUSETTS GENERAL HOSPITAL. Boston, Mass. 1893 3524 1894 1896 1897 3406 4304 4079 1898 4807 Cases of Appendicitis. 84 61 Acute, 10 died .... 4 Chronic, died .... 16 Recurrent, 1 died. . 1 "After Appendici- tis," 1 died. 130 103 Acute, 14 died 7 Chronic, died .... 1 Recurrent, died . . 188 121 Acute, 16 died 34 Chronic, died .... 33 Recurrent, died. . 191 92 not specified, 7 died, 28 Acute, 11 died 3 Catarrhal, died. . . 50 Chronic, 3 died. . . . 18 Gangrenous, 3 died 262 134 "Appendicitis," 7 died. 103 " Acute, 5 died. 1 " Catarrhal, died. 24 Appendiceal Ab- scess, 3 died. 13 14 16 24 15 Operations. 71 13 died. Total Number of All Operations. 101 12 died. 157 15 died. 176 23 died. 146 Appendicectomy 20 died. 30 Abscess 3 died. 219 201 during attack 9 died. 18 Interval 2 died. 1641 1798 2294 1730 2103 THE MORTALITY FROM APPENDICITIS ? 47 MASSACHUSETTS GENERAL HOSPITAL — Continued. ■- (ft Cases of Appendicitis. •a Operations. Total Number of e3 0) *0h 9 All Operations. PH §■8 4816 3 1899 282 24 206 2421 146 Acute, 9 died 23 died. 19 " with general 60 peritonitis, 15 died. Interval, 2 died. 90 Chronic, died .... 27 Catarrhal, died. . . 1900 4640 326 405 2544 142 Acute, 10 died 37 180 Acute, 11 died. 37 Acute with general 37 " with General peritonitis, 27 died. Peritonitis, 27 died. 120 Chronic, died.... 94 Interval Operation, 27 Catarrhal, died. . . died. 94 Chronic, died. 1901 5094 333 36 330 2984 146 Acute, 6 died 30 died. Major— 1254 47 with general perito- 144 nitis, 30 died. Acute Appendicitis, 5 93 Chronic, died .... died. 47 Catarrhal, died. . . 41 Acute with general peri- tonitis, 25 died. 20 Chronic, died. 55 Catarrhal, died. 1902 4936 361 27 315 3266 1 Acute with general 28 died. Major— 1328 peritonitis and intes- 136 Acute, 10 died. tinal obstruction, 1 |26 Acute with general died peritonitis, 16 died. 61 Chronic, 2 died. 2 with Intestinal Ob- struction, died. 92 Catarrhal. died. 1 with tubercular men- ingitis, 1 died. 131 Chronic, 1 died .... 48 Catarrhal, died. . . 31 Acute with General Peritonitis, 17 died. 147 Acute, 7 died 48 HAS SURGICAL TREATMENT LESSENED MASSACHUSETTS GENERAL HOSPITAL — Continued. 1903 1904 1905 5080 5204 Cases of Appendicitis. ■ 5096 190615075 376 195 Acute, 8 died . ... 36 Acute with General Peritonis, 16 died. 1 Acute with intestinal obstruction, 1 died. 34 Catarrhal, died. . . 110 Chronic, Odied.... 427 219 Acute, 6 died. . . . 32 Acute with general peritonitis, 18 died 1 Acute with intestinal obstruction, 1 died 19 Catarrhal, died. . , 133 Chronic, died.... 24 25 439 218 Acute, 4 died.. . . 30 Acute, General Peri- tonitis, 15 died. 8 Internal obstruction, 3 died. 1 Acute with Mesen- teric Thrombosis, died 58 Catarrhal, died . . 129 Chronic, 1 died 491 239 Acute, 9 died 23 Acute with General Peritonitis, 11 died. 70 Subacute, died . . . 159 Chronic, died .... Operations. Total Number of All Operations. 23 20 421 23 died. During attack, 342—23 died. 188 Acute, 9 died. 21 " with general peritonitis, 14 died. 53 Chronic, died. 70 Catarrhal, died. Interval, 79, died. 490 24 'died. 356 during attack. 209 Acute, 8 died. 28 with general perito- nitis, 16 died. 55 Chronic, died. 64 Catarrhal, died. 460 24 died. 372 during attack. 212 Acute, 6 died. 29 with general perito- nitis, 15 died. 79 Chronic, 2 died. 55 Catarrhal, died. 88 Interval, died 537 20 died. 431 during attack. 224 Acute, 8 died. 22 Acute, with general peritonitis, 10 died. Ill Chronic, 1 died. 74 Subacute, died. 62 Interval, died. 44 Normal Appendix removed during other operation, 1 died. 3109 Major— 1374 3271 Major— 1482 3182 Major— 1439 2988 Major— 1422 THE MORTALITY FROM APPENDICITIS ? 49 REPORTS OF LYNN HOSPITAL, Lynn, Mass. Year. Total No. of Patients. No. of Cases of Appendicitis. Died. Operations. 6 1890.... 1891.... 1892 327 385 424 435 465 551 638 800 772 1,037 1,047 1,117 1,263 1,441 1,721 1,846 9,462 4,797 ] 2 1 -..-.. 6 9 1 5 2 1 8 5 2 4 2 o O 9 3 23 22 1 1 83 81 92 1893.... 1894 5 ? 9 4 14 (1 died). 19 (8 died). 10 (5 died). 29 (2 died). 35 (4 died). 39 (2 died) . 47 (3 died). 50 44 (3 died). 244..... ... 84 116 1895.... 1896.... 1897 1898.... 1900 1901.... 9 22 28 14 31 38 74 274 321 314 469 498 1902.... 41 478 1903 1904.... 1905.... 22 52 51 389 863 972 1906.... 55 1.199 1900 and after. Before 1900 290 92 4,968 1,439 63 14,259 382 45 307 6,407 50 HAS SURGICAL TREATMENT LESSENED REPORTS OF MALDEN HOSPITAL, Malden, Mass. Year. 1893. 1894, 1896, 1897 1898, 1899, 1900, 1901, 1902 1903 1904.... 1905.... 1906 1907.... 1900 and after. Before 1900, 100 163 183 245 248 249 307 282 Cases of Appendicitis. 2,937 1,700 4,637 0. 1. 4, 5, 12, 7, 12. 25. 295! 16 351 34 389 45 456 63 542 65 622 316 42 3 1 3 14 358 19 Operation. 4(0 died) 6 (0 died) 12 (2 died) 5 (0 died) 11 (0 died) 10 Acute (1 died) 4 Interval (0 died) . . . 1 Abscess (0 died) . . . 7 Acute (1 died) 4 Interval (0 died) . . . 1 Abscess (0 died) . . . 8 Interval 22 Acute (2 died) 1 Abscess 1 Septicaemia (1 died) 42 (2 died) 64 (0 died) 69 (1 died) 70 (3 died) 304 (11 died) 38 (3 died) 342 35 43 45 83 130 133 111 173 173 180 152 206 264 302 1,429 580 2,009 THE MORTALITY FROM APPENDICITIS ? 51 REPORTS OF PATERSON GENERAL HOSPITAL. Patbrson, N. J. Year. 1900 and after. 1,010 961 1,154 1,510 1,638 1,628 1,583 1,562 1,525 1,517 1,629 1,553 1,598 1,760 11,145 9,484 20,629 No. of Cases Appendicitis. 3 3 9 11 36 19 22 27 50 31 70 36 46 60 330 103 433 Died. 1 2 6 2 1 3 7 6 9 4 4 5 38 12 50 9 3 31 12 18 15 31 29 62 47 42 59 285 73 358 £<2 133 284 154 391 530 556 428 465 595 456 694 527 429 519 3,685 2,476 6,161 52 HAS SURGICAL TREATMENT LESSENED REPORTS OF S. R. SMITH INFIRMARY, New Brighton, Staten Island, N. Y. Teak. IH H Cases of appendicitis. Died. Opebation. 6 <§3.2 1895.... 571 589 744 991 1,036 16 10 2 died 2 2 4 5 11 5 (2 died). 11 (3 died). 17 (5 died). 69 1896.... 1897 .... 1898. . . . 16 14 2 died 16 2 Catarrhal, died 1 Chronic, died. ..... ... 1 Gangrenous, died 12 Suppurative, 4 died 37 15 Acute Recurrent, 1 died. . 11 Suppurative, 3 died 1 Perforative, died 2 Chronic, died 201 236 307 44 1899.... 3 Catarrhal, died 4 Chronic Recurrent, 1 died. 1 Gangrenous, died 40 3 Acute Catarrhal, died . . . 294 THE MORTALITY FROM APPENDICITIS ? 53 S. R. SMITH INFIRMARY — Continued. Year. l«5.g rt S3 H Cases of Appendicitis. Died. Operations. 6 a 1900 .... 1,125 86 14 Acute Recurrent, 1 died . . 20 Acute Catarrhal, 2 died. . . 28 Acute Gangrenous, 6 died. 24 Suppurative, 7 died 16 80 526 1901.... 1,178 54 2 Acute Recurrent, died . . 6 Chronic, died. 3 54 323 20 Acute Catarrhal, 1 died . . 33 Gangrenous, 2 died 3 Suppurative, died 1902.... 1,297 83 28 Acute Catarrhal, died. . . 31 Acute Gangrenous, 6 died. 11 Acute Recurrent, died. . 3 Acute Suppurative, died. 9 Chronic, 1 died 7 76 468 1903 1,584 70 19 Acute Catarrhal, died. . . 25 Acute Gangrenous, 1 died. 1 Acute Recurrent, died . . 9 Acute Suppurative, 1 died. 16 Chronic Recurrent, died. 65 614 1904 .... 1,599 83 22 Acute Catarrhal, 1 died. . . 23 Chronic, died 3 83 697 19 Gangrenous, died 19 Suppurative, 2 died 54 HAS SURGICAL TREATMENT LESSENED S. R. SMITH INFIRMARY — Continued. Yeak. H Cases of Appendicitis. Died. Opeeations. i — ■ — o £<2 S ft O — S H ■g<2 Ho2 1904.... 4,236 4,034 4,404 213 8 Catarrhal 57 Acute Appendicitis, 5 died . . . 15 Gangrenous, 4 died 12 19 14 220 (12 died.) 220 (15 died.) 196 (16 died.) 1,897 41 with Abscess, 2 died 69 Chronic, 1 died 5 Appendicular Colic. . 2 Appendicitis and movable kid- ney 1 Acute Appendicitis and Acute Pancreatitis 1905.... 5 Appendicitis 223 45 " Appendicitis," "2 died 7 Gangrenous Appendicitis, 1 1 died 2,092 31 Acute Appendicitis 22 Acute Appendicitis with Spreading Peritonitis, 4 died. 9 with General Peritonitis, 7 died. 27 Chronic 56 Appendicitis with Abscess, 5 died 24 Catarrhal 1906.... 201 2 Appendicular Colic 1,959 54 Acute Appendicitis, 2 died . . . 18 Subacute Appendicitis 48 Chronic Appendicitis 48 Appendicitis with Abscess, 2 died 7 Appendicitis with General Per- itonitis, 5 died 10 Acute with spreading Perito- nitis, 5 died THE MORTALITY FROM APPENDICITIS ? 61 ROOSEVELT HOSPITAL — Continued. Ykar. Total No. of Patients. Cases ok Appendicitis. Died. a o t s O A Pr? ■ Y - ' 1900 and after. Before 1900. 27,064 31,983 1,223 689 ■ 104 96 1,231 679 8,952 13,062 59,047 1,912 200 1,910 22 014 62 HAS SURGICAL TREATMENT LESSENED REPORTS OF GERMAN HOSPITAL, Philadelphia, Pa. 1891.. 1892.. 1893.. 1894 1895, 1896.. 1,568 1,646 1,769 1,885 1,882 2,026 Cases of Appendicitis. Medical Report: 1 Typh litis Medical Report : 3 Appen dicitis Surgical Report : 5 Appendicitis, perfora tive 2 Typhlitis (No operation.) Medical Report : 2 Perityphlitis ( 1 died) 1 Appendicitis . ." Surgical Report: 7 Appendicitis. . , Medical Report : 5. 3 Acute 2 Chronic Surgical Report : 53. 15 Acute (6 died) 38 Chronic (0 died) Medical Report : 12. 8 Acute 4 Chronic Surgical Report : 95. 14 Acute (3 died) 81 Chronic (4 died) Medical Report : 8 3 Acute 5 Chronic Surgical Report : 144 56 Acute (9 died) 88 Chronic (3 died) 12 Operations. (4 died.) (Abdominal Section.) 1 (Abscess incised.) (1 died.) (Abdominal Section.) 13 Acute (6 died). 39 Chronic. 10 Acute (5 died). 71 Chronic (2 died), 49 Acute (7 died). 81 Chronic (3 died). 151 425 303 386 387 562 THE MORTALITY FROM APPENDICITIS? GERMAN HOSPITAL-Continued. 63 Teak. 1(2 EH 1890 2,404 1900 . . 2,714 1902.. 2,596 1903.. 2,974 1904 2,647 1905. 2,973 c lses of Appendicitis. Medical Report : 8 5 Acute 3 Chronic Surgical Report : 223 109 Acute (13 died)... . 114 Chronic (1 died).. . Medical Report: 13(8 died) Surgical Report: 290 167 Acute (28 died) . . . 123 Chronic (1 died) . . . Medical Report: 3 1 Acute 2 Chronic Surgical Report : 447 290 Acute (38 died) 157 Chronic (ldied), Medical Report : 3 2 Acute 1 Chronic Surgical Report : 498 298 Acute (23 died) , 200 Chronic (0 died) , Medical Report : 4 2 Acute 2 Chronic Surgical Report : 484 323 Acute (30 died). . 161 Chronic (2 died) . Medical Report : 4 4 Acute (1 died) . Surgical Report: 530.. 308 Acute (35 died)., 222 Chronic (0 died), 14 37 Opeb \ 102 Acute (13 died), 98 Chronic (1 died), 2 (Appendicitis, Ab- scess.) (Abdominal Section.) 144 Acute (26 died). 124 Chronic (1 died). 39 284 Acute (37 died). 153 Chronic (1 died). 23 32 36 285 Acute (22 died) 190 Chronic (0 died), 304 Acute (25 died), 155 Chronic (2 died), 302 Acute (33 died) 211 Chronic -■ — 8*1 *22 937 1.210 1,874 1.441 1,596 64 HAS SUKGICAL TREATMENT LESSENED GERMAN HOSPITAL — Continued. Yeak. 1906. 3,376 1900 and 17,280 after. Before 1900. 13,180 30,460 Cases of Appendicitis. Medical Report : 2 1 Acute 1 Chronic Surgical RejDort : 617 342 Acute (18 died). . . 275 Chronic 2,895 569 3,464 18 185 44 229 Operations. 329 Acute (15 died), 266 Chronic. 2,749 (162 died). 475 (42 died). 8,224 (204 died). 1,772. 8,635 2,885 11,520 Cases 1900 and after. Operations 1900 and Aftee. 1900 . , 1902 . , 1903 . 1904. 1905., 1906., Acute. 180 291 300 32& 312 343 Died. 28 38 23 30 35 18 Chronic. Died. 123 1 159 1 201 163 2 222 276 1,751 172 1,144 (60%) (9.8%) (40%) (of all deaths.) 4 1891 .... 1 1892 .... 10 4 10 1 18 6 22 3 59 9 114 13 40 85 4 93 3 117 1 (41%) 234(15.3%)36 (59%) 335 (2,3%) 8 1,751 172 1,144 4 1,985 208 (57%) (10.4%) 1,479 12 C43%) (.8%) 1900., 1902 . , 1903 . 1904., 1905 . , 1906., 1892.. 1893 . . 1894.. 1895 . . 1896 . . 1899 , . Acute. 146 284 285 304 302 329 1,650 o 5 13 10 49 102 184 1,650 1,834 1834. 1390. 3,224 Died. 26 37 22 25 33 15 158 (9%) Before 1900. 4 1 6 5 7 13 Chronic. Died. 124 1 153 1 190 155 2 211 266 3,099 4 1 39 72 81 98 36(19%) 291 158 1,099 194 (10.5%) .Acute, 194 10 1,390 10 204(6.3%) THE MORTALITY FROM APPENDICITIS ? REPORTS OF ST. LUKE'S HOSPITAL, New York, N. Y. 65 Ykaii. 3 d oh H 1893 2.122 1894 2,300 1895 . . . 1,870 1896 1,439 1897 2,444 Cases ok ArrKMncms. 16 13, 2 died, Acute 1, died, Recurrent.. 2, 1 died, Chronic 3 died. 38 13, died, Acute 5, died, Chronic 11, 3 died, Perforative. 9, died, Catarrhal . . 3 died. 17 10, 1 died, Acute 5, 4 died, Perforative 2, died, Catarrhal. . 5 died. 38 16, 2 died, Acute 5, died, Chronic . . . . 1, 1 died, Perforative . 6, 1 died, Catarrhal . . 4 died. 56 3, died, Recurrent . . 15, 3 died, Acute 8, died, Chronic. . . . 14, died, Catarrhal . . 3, 3 died, Gangrenous 13, 2 died, Perforative 8 died. 10 (2 died) 1 (1 died) 13 a 11 (3 died) 7 36 (3 died) 15 5 1 4 (1 died) (4 died) 15 (5 died) (2 died) (1 died) (2 died) 25 (4 died) 13 (3 died) s 14 3 13 (3 died) (2 died) 54 (S died) r, 6 03 — a 517 650 452 481 852 66 HAS SURGICAL TREATMENT LESSENED ST. LUKE'S HOSPITAL — Continued. Yeak. fcg +3 rt 1898 2,656 1899 2,474 1900 2,370 1901 2,889 Cases of Appendicitis. 10, 7, 2, 5, 2, 25, 36, 18, 7, 15, 3, 26, 1, 38, 1, 11, 17, 6, 10, 16, 17, 66, 5, 4, 4, 27, 20, 17, 3. 51 died, Recurrent died, Acute died, Chronic died, Catarrhal 1 died, Gangrenous 6 died, Perforative 7 died. 106 died, Recurrent died, Acute died, Chronic died, Catarrhal died, Gangrenous 12 died, Perforative Suppurative Acute 12 died. 129 died, Recurrent died, Acute 1 died, Chronic died, Catarrhal 2 died. Gangrenous 6 died, Perforative 9 died, Suppurative 18 died. 163 died, Acute died, Chronic died, Catarrhal died, Gangrenous died, Perforative died, Recurrent 2 died, Suppurative Acute.. died, with Abscess 3 died, with General Perito- nitis 5 died. 10 7 2 5 2 25 Jz;0a . Year. S'-g PPh Cases of Appendicitis. OPERATIONS. 131 1904 .... 1,739 358 358 1,551 54, 1 died, Acute, with Perfor- ation or Gangrenous (8 died) 77, Acute, without Perforation . . 8, 3 died, Acute, with General Peritonitis 108, Chronic and Recurrent 5, Appendicitis, complicated by Inguinal Hernia .... 71, 1 died, Implicating Adnexa- 30, 3 died, Appendicitis and Cho- lecystitis 9 Appendicitis and Movable Kidney 8 died. 1905.... 2,205 74, 16, 66, 166, 10, 9,5, 302 3 died, Acute, with Perfor- ation or Gangrenous 4 died, Acute, with General Peritonitis ... 3 died, Acute 3 died, Chronic and Recurrent Complicated with Inguinal Hernia Involving Adnexa 302 1,802 20, Appendicitis and Cholecystitis B, 1 died, Appendicitis, with Movable Kidney. . . . 2, Appendicitis-Tuberculosis.. . . 5, 1 died,Corcinoma of Appendix- 15, Appendicitis Chronic, with Ul- ceration of Stomach . 15 died. 82 HAS SURGICAL TREATMENT LESSENED AUGUSTANA HOSPITAL — Continued. Year. O . • CD Cases of Appendicitis. Operations. OB Hoc* 1906 .... 2,353 474 168, 2 died, involving Adnexa .... 59, 5 died, Acute with Abscess. . . 2, Acute Perforated 474 (20 died) 1,902 60, 1 died, Acute 4, 1 died, Acute Gangrenous. . . 15, 11 died, Acute with Diffuse Peritonitis 4, Appendicitis, complicated with Gastric TJlcer 2, Appendicitis, complicated with Intestinal Obstruction 2, Appendicitis-Tubercular 20 died. 2,175 2,173 11,203 1900 13,043 (79 died) (78 died) and after Before 156 156 1900 2,596 ( 5 died) ( 5 died) 2,510 2,331 2,329 15,639 (84 died) (83 died) 13,613 THE MORTALITY FROM APPENDICITIS ? REPORTS OF ST. MARY'S HOSPITAL, Rochester, Minn. 83 1895 1896 1897 Total No. of Patients. 1898 1899 1900 661 257 Medical Patients, 6 died . . 870 210 Medical Patients, 2 died . 913 210 Medical Patients, 3 died 978 123 Medical Patients, 10 died . 1,085 • 170 Medical Patients, 5 died 1,286 total pa- tients op- erated . . . 1,166 47 Medical Patients, 6 died . . 1,413 total pa- tients op- erated. . . 3.2 151 247 No. Casks Appendicitis. 11 6 Suppurative 5 Chronic Medical Report : 2 Acute Surgical Report : 21 15 Suppurative 6 Chronic Relapsing. . . Medical Report : 4 Acute Surgical Report : 42 (1 died) 14 Suppurative 28 Subacute and Chronic Medical Report: 2 Acute .... Surgical Report: 47 (1 died) 26 Acute 21 Chronic Medical Report : 2 Acute 1 Chronic Surgical Report: 94 (2 died) 42 Acute 52 Chronic and Recurrent Medical Report : 1 Acute Surgical Report: 180 (4 died) 73 Acute and Suppurative 107 Chronic and Recurrent 15 5 14 28 26 21 42 52 107 3=- — . S3 3 5-9J-2 752 (111 Ab- dominal) 881 (196 Ab- dominal) 966 (251 Ab- dominal) 1,130 (322 Ab- dominal) 1,619 (470 Ab- dominal) 1,821 (612 Ab- dominal) 84 HAS SURGICAL TREATMENT LESSENED ST. MARY'S HOSPITAL — Continued. 1901 1902 1903 1904 1905 total no. of Patients. 1,422 28 Medical Patients, 7 died . . 1,767 total Pa- tients op- erated . . . 1,543 20 Medical Patients, 6 died . . 2,019 total Pa- tients op- erated . . . 1,777 20 Medical Patients, 9 died... 2,300 total Pa- tients op- erated . . . 2,093 14 Medical Patients, 4 died . . 2,501 total Pa- tients op- erated.. . 2,727 20 Medical Patients, 10 died . 3,160 total Pa- tients op- erated . . . °1 345 476 523 408 433 No. Cases Appendicitis. Medical Report : 1 Acute (0 died) Surgical Report : 300. 125 Acute and Suppurative 175 Chronic Medical Report : 1 Acute Surgical Report : 342. 143 Acute and Suppurative l 2 Acute and General Pe- ritonitis 197 Chronic Medical Report : 3. 3 with General Perito- nitis Surgical Report: 403(11 died) 151 Acute and Suppurativej 7 252 Chronic I 1 526 131 Acute and Suppurative 8 with General and Sep- tic Peritonitis 387 Chronic Medical Report : 2 (0 died) Surgical Report: 7 54 (10 died) 276 Acute, with Suppur- ation 11 Acute, with General Septic Peritonitis. 467 Chronic 125 172 143 197 151 252 131 8 387 276 11 467 THE MORTALITY FKOM APPENDICITIS ? ST. MARY'S HOSPITAL — Continued. 85 K < M Total No. l'ATIISNTS. No. Cases appendicitis. •a" 5 i§ _ — 3 1906 3,299 13 Medical Patients, 2 died.. 616 1063 Medical Report: 2 (0 died) Surgical Report: 924 (8 died) 371 Acute and Suppurative 10 Acute, with Diffuse 543 Chronic 2 3 1 1 5 1 371 10 543 433 6 702 4,770 (2750 Ab- dominal) 3,915 total Pa- tients op- erated . . . 3,748 6 Medical Patients, not oper- ated, 6 died .... 1907 Medical Report: 4. Surgical Report: l,141(7died) 433 Acute and Suppurative 6 Acute, with Diffuse Peritonitis 702 Chronic 5,523 (3215 Ab- dominal) 4,811 total Pa- tients op- erated . . . 1900 and after. Be- fore U900 21,886 4,658 4,784 (49 died) 226 ( 5 died) 4765(44died) 215( 5died) 26,162 5,348 26,544 5,010 (54 died) Including 25 from Medical Report with 5 deaths. 49 30(49died) 31,510 86 HAS SURGICAL TREATMENT LESSENED REPORTS OF ST. JOSEPH'S HOSPITAL, Paterson, N. J. 3 891. 1892. 1893. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1903. 1904. 1905. 1906. 1900 and after. Before 1900. 2 a £.2 806 823 846 1,143 1,305 1,500 1,559 1,474 1,980 1,685 1,357 1,466 1,410 1,486 9,384 9,456 18,840 Cases of Appendicitis. 1 2. 5. 17. 13. 12, 25, 33, 42. 37 59, 51 29 27 243 108 351 5 2 4 10 10 7 7 3 43 21 64 Operations. 2 (0 died) . . . 9 (5 died)... 10 (0 died) . . . 7 (2 died) . . . 24 (4 died) . . . 21 (5 died) . . . 37 (7 died)... 34 (8 died) . . . 46 (5 died)... 41 (5 died) . . . 28 (7 died) . . . 23 (3 died) . . . 209 (35 died).. 73 (17 died).. 282 (52 died) 2~S .g<2 80 124 108 274 335 289 434 411 469 457 332 445 414 287 2,404 2,055 4,459 THE MORTALITY FROM APPENDICITIS? 87 REPORTS OF MARGARET PILLSBURY GENERAL HOSPITAL, Concord, N. H. \ BAB. 1894.. 1895.. 1896.. 1897.. 1898.. 1899.. 1900.. 1901.. 1902.. 1904.. 1905 . . 1906.. 1900 and alter. Before 1900. 170 223 216 203 251 213 303 239 352 379 339 440 1,172 1,290 2,462 Cases of Appendicitis. 1, 2 1, 2, 3, 6; 6, 7. 9 13. 17, 29. 81, 15. 96. 2 2 3 4 2 5 3 9 7 16 42 11 53 81 36 48 56 53 73 79 78 76 87 100 116 527 347 874 88 HAS SURGICAL TREATMENT LESSENED REPORTS OF RHODE ISLAND HOSPITAL, Providence, R. I. O . YEAK. 6-2 1891.. 1,061 1892.. 1,322 1893.. 1,476 1894.. 1,730 1895.. 2,046 1896.. 2,283 No. of Cases. Surgical Report: 3 Perityphilitis Medical Report : 2 " Appendicitis " Surgical Report : 4 3 Perityphilitis 1 " followed by Septic Peritonitis. Medical Report: 2 Surgical Report : 5 3 " Appendicitis " 1 witli Abscess of Liver. . . 1 with Erysipelas Surgical Report: 14 12 " Appendicitis " 1 with Abscess of Liver. 1 Recurrent Medical Report : 5 Surgical Report: 28 23 " Appendicitis " 4 Recurrent 1 with Suppuration Medical Report : 4 Surgical Report : 25 Operations. 16 (2 died.) 19 (2 died.) 14 5=S 324 363 407 743 685 THE MORTALITY FROM APPENDICITIS? RHODE ISLAND HOSPITAL — Continued. 80 1897 1898 1899, 1900 2,421 2,516 2,750 3,185 No. of Cases. Medical Report : 6 Surgical Report : 29 27 "Appendicitis " 2 " with Gen- eral Peritonitis (2 died) Medical Report : 5 Surgical Report : 51 4 Catarrhal 33 Suppurative (3 died) . . 3 Chronic 1 with Fecal Fistula 10 with General Peritoni- tis (8 died) Medical Report : 1 Surgical Report : 49 17 Catarrhal 1 Chronic 6 Recurrent 1 " with Abscess. 18 " with Abscess, (1 died). 6 with General Peritoni- tis (6 died). Medical Report: 3 Surgical Report : 65 15 Catarrhal 36 with Abscess (4 died) . 7 Acute Perforative (6 died). 7 Chronic 11 10 Operations. 22 (5 died) 4 General Peritonitis (4 died). 8 Abscess (1 died). 10 Removed Appen- dix. 41 (11 died) 19 Abscess incised. 12 with General Per- itonitis (10 died). 10 removal of Apj)en- dix (1 died). 35 (7 died.) 13 Appendicectomv. 15 Abscess incised (3 died). 4 with General Per- itonitis, Laparot- omy (4 died). 1 "Appendicitis," Explorative Lapa- rotomy. 61 (10 died.) 14 Appendicectomv. 4 with Abscess, Ap- pendicectomy ( 1 died). 29 Abscess incised (1 died). 11 Perforative (8 died). 3 Chronic. 760 792 846 900 90 HAS SURGICAL TREATMENT LESSENED RHODE ISLAND HOSPITAL — Continued. Year. 1901 1902. 1904. 3,465 3,282 3,973 No. of Cases. (1 Medical Report: 3 Surgical Report : 94 15 Catarrhal 20 Chronic (1 died) . . . 4 with Fecal Fistula died) 13 with General Peritonitis (9 died) 35 Suppurative (5 died).. 6 Ulcerative (2 died) .... 1 with double Salpingo- oophoritis Operations. Medical Report : 1 Surgical Report : 105 . 25 Catarrhal (1 died) 10 Chronic 2 with Fecal Fistula 68 Suppurative (20 died) Surgical Report : 143 29 Acute Catarrhal (1 died) 29 Chronic 7 Gangrenous (4 died).. . 42 Suppurative (9 died) . . 36 Ulcerative (2 died). . . . (12 died.) 19 with Abscess, drained (4 died) 50 Appendicect oray (7 died). 6 with General Per- itonitis (1 died). 1 with Fecal Fistula. 1 with Salpingitis. 108 (22 died.) 27 Abscess drai n e d without Appendi- cectomy (3 died). 65 with Abscess drained and ap- pendice c t o m y (11 died). 8 with General Per- itonitis (5 died). 8 with Second Ex- plo7'ation(3died) 134 (19 died.) 23 Abscess incised and drained (7 died). 110 Appendicectomy (12 died). 1 Appendicectoray with Salpingo- oophorotomy. THE MORTALITY FROM APPENDICITIS ? 91 RHODE ISLAND HOSPITAL — Continued. ".2 o a H 1905 4,261 1906 4,487 NO. of Cases. Surgical Report : 177 1 with Fecal Fistula 2 with Inguinal Hernia. . . . 12 Acute 25 Acute Catarrhal 1 Acute with Pelvic Ab- scess 1 Acute with Perinephritic Abscess 37 Chronic 1 Chronic with Axillary Ode- nitis 2 Chronic with Fecal Fis- tula (1 died) 1 with General Peritonitis, Chronic (1 died) 10 Gangrenous (1 died) 4 Gangrenous with General Peritonitis (4 died). . . . 3 Sub-acute 11 Suppurative 3 Suppurative with Gen- eral Peritonitis 51 Ulcerative (9 died) 8 Ulcerative with General Peritonitis 1 Ulcerative with Multiple Abscess 1 Sinus Recurrent Medical Report : 2 (2 died) Surgical Report : 169 9 Acute (1 died) 5 Acute with Abscess (1 died) 1 Acute with Abscess and Fecal Fistula 14 Acute Catarrhal 1 Acute Catarrhal with Pel- vic Cellulitis 16 is Operations. 131 (25 died.) 110 Appendicectomy (22 died). 21 Abscess incised and drainage (3 died). 33 2 24 61 168 (19 died).) Abscess incised and drainage (6 died). Appendicecto ra y (2 died). Appendic e ct o my with drainage (11' died). 2,475 2,130 92 HAS SURGICAL TREATMENT LESSENED RHODE ISLAND HOSPITAL — Continued. Year. 1906.. 4,487 6 Acute Gangrenous 1 Acute with General Peri- tonitis 5 Acute Perforative 14 Acute Perforative with Abscess (2 died) 12 Acute Perforative with General Peritonitis (7 died) 1 Acute Perforative with General Peritonitis and Scarlet Fever 1 Acute Perforative with with Perinphritic Ab- scess and Scarlet Fever (1 died) 41 Acute Ulcerative (1 died). 14 Acute Ulcerative with Ab- scess (1 died) 5 Acute Ulcerative with General Peritonitis (1 died) 18 Chronic 3 Chronic Catarrhal 1 Chronic with Chronic Sal- pingitis 1 Chronic with Cystic Ovary 1 Chronic with Fecal Fistula and General Miliary Tu- berculosis 1 Chronic with Gastroptosis. 1 Chronic Obliterative 4 Gangrenous with Abscess. 2 Gangrenous with General Peritonitis (1 died) .... 1 Gangrenous with Perfora- tion, General Peritonitis and Subphrenic Abscess. 4 Subacute Catarrhal 1 Suppurative ... Operations. 1 Appendicectomy with cholecysto- toray. 2 Appendicectomy with double sal- pingo -oophorec- tomy. 1 Appendicectomy with drainage mesenteric cyst. 1 Appendicectomy with oophorec- tomy. _ 1 Appendicectomy with removal of mesenteric lymph glands. THE MORTALITY FPOM APPENDICITIS ? RHODE ISLAND HOSPITAL — Continued. i Ykar. £.2 No. of Cases. ~ Operations. &2g H o 3 14 1907 . . 4,771 Medical Report : 1 194 2,197 Surgical Report : 205 (15 died.) 5 Acute (0 died) 27 Appendicitis, in- 37 Acute with Abscess (3 cision and drain- died) age (5 died). 37 Acute Catarrhal (0 died) . 17 Gangrenous 1 Acute Gangrenous with 96 Appendicectomy Abscess (1 died). 2 Appendicectomy 4 Acute with General Peri- tonitis (3 died) with curettage. 20 Acute Perforative (4 died) 68 Appendicectomy 4 Acute Perforative with with drainage (9 Abscess died). 4 Acute Perforative with 1 Appendicectomy General Peritonitis (2 with DoubleSal- died) pingo-oophorec- tomy. 26 Acute Ulcerative 6 Acute Ulcerative with Ab- scess (1 died) 30 Chronic (1 died) 5 Chronic Catarrhal 5 Chronic Catarrhal with Chronic Salpingitis .... 2 Chronic with Cystic Ovary 1 Chronic with Retrover- sion of Uterus 1 Chronic with Tubercular 1 Gangrenous with Perfora- tion and General Perito- nitus and Subchronic Abscess 2 Subacute 1 Empyema of Appendix . . 1900 and 29,424 965 . . 113 873 (122 died). 150 (27 died). 11,609 5 167 Before 17,605 233 30 143 45,029 1,198 1,023 (149 died). Iti 7 7t> 94 HAS SURGICAL TREATMENT LESSENED REPORTS OF ST. MICHAEL'S HOSPITAL, Newark, N. J. Year. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1903. 1904. 1905. 1906. 1907. 1900 and after. Before 1900. 1,814 1,505 1,489 1,860 2,016 2,151 2,223 2,342 2,193 2,347 3,073 2,135 2,188 16,501 10,835 27,336 Cases of Appendicitis. 5 13 8 14 9 21 31 30 29 32 48 41 51 262 70, 332. 44 Operations. 3 5 4 8 8 4 23 20 21 22 39 32 44 (1 died) (0 died) (1 died) (2 died) (1 died) (0 died) (1 died) (1 died) (2 died) (2 died) (7 died) (1 died) (3 died) 211 (17 died) 32 (5 died) 243 (22 died) — 3 N H O >-. 756 754 763 774 993 838 942 968 1,501 1,532 837 1,238 1,086' 8,104 4,878 12,982 THE MORTALITY FROM APPENDICITIS ? 95 REPORTS OF ST. LUKE'S HOME AND HOSPITAL, Utica, N. Y. Year. EH Cases of Appendicitis. S DO a a> A O Total No. of all Ope- rations. 1895.. 353 443 377 387 457 521 513 544 604 594 579 814 1,108 5,277 2,417' 3 1 1 1 1 1 4 7 15 1 16 3 3 3 4 10 11 8 10 22 13 20 31 63 178 23 163 1896.. 4 214 1897. . 5 189 1898.. 5 205 1899.. 1900.. 1901.. 10 13 9 183 245 245 1902.. 10 258 1903.. 22 297 1904.. 1905 . . 14 22 264 297 1906.. 1907.. 30 66 415 624 1000 and after. Before 1900. 186 27 2,645 954 7,694 213 201 3,599 96 HAS SURGICAL TREATMENT LESSENED REPORTS OF ORANGE MEMORIAL HOSPITAL, Orange, N. J. Year. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1902. 1905. 1906. 1900 and after. Before 1900. OS <3 H 795 800 784 785 751 824 729 798 1,210 1,063 1,121 4,192 5,468 9,660 Cases of Appendicitis. 5 5 11 6 19 20 16 8 44 56 48 156 82 238 Operations. 4 6 4 19 13 10 43 56 50 (1 died) (4 died) (2 died) (4 died) (2 died) (2 died) (6 died) (8 died) (5 died) 159 (21 died) 46 (13 died) 205 (34 died) 12 135 136 134 138 138 146 123 129 172 303 285 889 950 1,839 THE MORTALITY FROM APPENDICITIS? 07 ■< £ 'A O O « *-0C8T '9061 Stt in co -'Q«i-iooo:H' c. co i- t- x coo i- pie» i- ci in o B -+ i-i 55 -r _ n — < i-';:ir.:iiip-o tern m ci fh »-< :in:i:iH;i:-c.r. c i co c) «h c? ic •* »h co •-< c£ H co x — ic i-h — en o joccoooto: K -■« CO i-l r-l CI ■ • • co n ~rrab~x t- ci -*■ -* cd t — p oc i-t .1 x -r en »c -h tn hi-oih «* co co -r x en co ci co ic .-■-. :-. i - co oo :ir.rtOKI«« :o t :i r: «f • co ci en co c~ ic i- co *c -ooioc pa* 006X ocwioc-ri — t<:i-ti^i"cor.i- HHiHfl co ic :c :o eg cki CI CI Q IC -r I- CO CO en CO en 11 f ■-< ci c5 co — n ci r- r- w • -* en co ic rrcii-H^J* i-*nHir co"co -* 00 CO CO 00 .U0 CN w « •poaa^ enciooTtxt~i-cii-iccocicco»icncocn ciict^wicoioiMciin xcox*c©iOT» r-l lC tP CO (N CO CN iH • • ,-t CO CO Ol Od CO 4> 00 ~* iO © CO CO rt< tJ< — S 3 ( •mox ?32 < r- tji no co ci a: i -J C- IO CO H c d "C* CI CI '0061 pa-B 0061 CO C CO CO CO — -T IQ C lO nffiOCOO--MOK ■CiH-WCOIQClt- • X Ci • ooencocciioocoxco >hs : -f h co co (M co • ci: CN ii CO ^H iC CI CI OC CO CO CI CO -f co en i-< 00 •moi icicoiiioocn--ooiccNi— cni-iiciccnt--oOTt*c-ic^r-t«i-*xcnt-cni-i aiCII-C J -rcCMCCCOHCC0)I*T)»*> ■i — u D c« g i NLl - +- 1 5p»«g ^* - CO >*r~) co cu^^r^i g^- 1 § m-i S -1! ^ 8 if a - r TS _ S O 1*K<0 Q_^ S S V ^ O CD - C .- ci c m DPH«xcjpq,j ^ : br • co <-l .' CO : -" : & \t : S 3 :c S !3 to rt * o _cjhHgq g*5.S O i-43 M P +^> ~'£ o S o s a CD -JC 5.S a co •" © i) co >, • Ohti ^ •-- — CJ .&CC! CD C. oi *d ja co C --- c g S i-S ed ^- ^■^ e-> . Ja-2 d)„-cJ a— c 1 5 " S ° a* — 73 ee ■^ O c3 Kco S»» •^ ic x i- oo o c h m co J ic cc r- oo c c h fM ?:■ «t o ci- cc c Q h ? i co n - cn o 1892 481 473 483 619 669 819 779 779 909 995 1,014 1,049 1,130 5,876 4,323 2 1 1 1 2 5 5 2 1 5 5 7 7 4 29 17 1893 4 2 1894 1896 5 11 1 4 1897 14 14 1898 25 17 1899 20 18 1900 19 6 1901 16 10 1902 1903 10 27 10 27 1904 1905 42 46 44 39 1900 and after. 163 136 Before 1900. 81 56 10,199 244 46 192 THE MORTALITY FROM APPENDICITIS ? 113 REPORTS OF ST. LUKE'S HOSPITAL, Chicago, III. Year. Total No. of Patients. Cases of Appendicitis. Died. 1892 1,504 1,471 1,593 1,563 1,761 1,967 2,312 2,312 9,859 5 o 1894 27 4 1896 21 o 1897 82 2 1898 1899 25..., 22 3 3 1902 1900 and after. 66 66 7 7 Before 1900. 132 12 12,171 198 19 114 HAS SURGICAL TREATMENT LESSENED REPORTS OF CHARITY HOSPITAL, New Orleans, La. Year. 1893 1894 1895 1896 1897 1898 1899 1900 1900 and after. Before 1900. Total No. of Patients. 7,728 8,480 7,734 7,281 8,816 9,812 9,064 8,330 8,330 58,915 67,245 Cases of Appendicitis. Died. 4 4 1 13 9 12 3 12 4 15 3 15 2 15 2 60 20 75 22 THE MORTALITY FROM APPENDICITIS ? 115 Year. 1891.. 1892.., 1893.. 1894.. , 1895... 1896.. . 1897 . . , 1898 1899 REPORTS OF BUFFALO GENERAL HOSPITAL, Buffalo, N. Y. 1,829 2,009 2,087 1,913 2,109 2,075 2,087 2,107 2,271 Cases of Appendicitis. 2 3 16 14 35 72 62 17 Acute Catarrhal, died 15 Chronic, died 2 Gangrenous, 1 died .... 1 Recurrent, died 27 Suppurative, 9 died . . . 69 20 Acute Catarrhal, died 9 Gangrenous, 2 died. . . . 15 Recurrent, 1 died 17 Subacute, died 8 Suppurative, 1 died. . . 65 24 Acute Catarrhal, died 7 Gangrenous, 6 died. . . . 13 Recurrent, died 4 Subacute, died 17 Suppurative, 2 died . . . 10 13 30 64 54 71 67 c ir — — a 490 499 616 537 841 848 781 930 649 116 HAS SURGICAL TREATMENT LESSENED BUFFALO GENERAL HOSPITAL — Continued. 1900. 1901 1902, 1903 1900 and after. Before 1900. ■3 cS 2,448 2,816 2,320 2,635 10,219 18,886 29,105 Cases of Appendicitis. 98 54 Acute Catarrhal, 1 died. 6 Gangrenous, 4 died 15 Recurrent, 4 died 8 Subacute, died 15 Suppurative, 5 died .... 85 45 Acute Catarrhal, 1 died 8 Gangrenous, 5 died.. . . 12 Recurrent, died 29 Suppurative, 1 died . . . 108 57 Acute, died 11 Gangrenous, 5 died . 12 Recurrent, died . . . 28 Suppurative, 4 died . 103 60 Acute, 1 died 16 Gangrenous, 1 died. . 10 Recurrent, died . . , 17 Suppurative, 3 died, 494. 338. 832, 14 90 84 79 101 354 319 673 1,100 1,139 1,004 972 4,215 6,191 10,406 THE MORTALITY FROM APPENDICITIS ? 117 REPORTS OF LAKESIDE HOSPITAL, Cleveland, Ohio. Year. o „; O fl Cases of Appendicitis. DlED. Operations. Total No. of All (ig- nitions. 1900.... 1901.... 1,780 1,909 2,227 3,168 54 8, died, Catai-rhal 26, 4 died, Circumscribed Ab- scess. . 3, 2 died, General Peritonitis . 17, 1 died, Chronic 45 18, died, Catarrhal 5, died, Circumscribed Ab- scess 7 o O 4 11 60 (8 died.) 35 (2 died.) 77 (4 died.) 97 (12 died.) 1,071 1,097 1902.... 4, 3 died, General Peritonitis. 18, died, Chronic , 82 11, 1 died, Catarrhal 1,606 32, died, Circumscribed Ab- scess 7, 3 died, General Peritonitis . 32, died, Chronic 1903 ... 97 10, died, Acute Catarrhal. . . . 43, 6 died, Circumscribed Ab- scess 8, 5 died, General Peritonitis. 2, died, Intraperitoneal Ab- 1,255 118 HAS SURGICAL TREATMENT LESSENED LAKESIDE HOSPITAL — Continued, Year. °« o's S3 .2 Cases of Appendicitis. Died. Operations. .- • — r< o £ 1907.... 2,805 124 37, died, Acute Catarrhal. . . . 39, died, Chronic 3 84 (3 died.) 1,564 33, died, Circumscribed Ab- scess 8, 3 died, General Peritonitis . . 7, died, Intraperitoneal Ab- scess 11,889 402 28 353 (29 died.) 6,593 THE MORTALITY FROM APPENDICITIS ? REPORTS OF ST. CATHERINE'S HOSPITAL, Brooklyn, N. Y. 119 Year. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 5« 2.162 2,230 2,150 2,250 2,283 2,308 2,235 15,618 Cases of Appendicitis. 6 7, 16. 21 50 58, 43 301 03 o Died. 0) Q. o 1 6 1 7 4 16 2 21 4 42 7 58 5 40 24 190 S2s 308 183 333 224 362 397 283 2,090 REPORTS OF AVANT-OGDEN MEMORIAL HOSPITAL, Elmira, N. Y. 1895 . . 1896 . . 1897 . . 1898.. 1899 . 1900.. 1901.. 1902 . . 1903 . 1905.. 1906 . . 1900 and after. Before 1900. 279 337 312 341 380 414 423 458 608 607 658 3,168 1,649 4,817 1. 1. 0. 9. 8. 9. 12 14, 18, 26, 38 117, 19 136 1 1 1 3 4 1 2 1 11 3 14 120 HAS SURGICAL TREATMENT LESSENED REPORTS OF CITY HOSPITAL, Quincy, Mass. Year. Total Number of Patients. Cases of Appendicitis. Died. 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1900 and after. Before 1900. 197 198 214 215 202 230 268 284 282 284 323 1,671 1,026 1 2 3 4 5. . 1 o 10 23 21 25 21 21 121 15 2 2 2 3 2 2 13 1 2,697 136 ! 14 THE MORTALITY FROM APPENDICITIS ? 121 REPORTS OF BROOKLYN HOSPITAL, Brooklyn, N. Y. Geo. R. Fowler, Surgeon. Year. O „; - +^ O 2 H Cases of Appendicitis. Died. .3 +3 s o E 1 " o ^ 1894 1,132 1,086 1,149 1,332 1,455 1,781 2,170 2,170 7,935 5 1 4 3 10 3 3 5 5 24 4 16 21 55 51 :-i4 74 74 181 475 16 210 1895 1896 24 57 271 525 1897 44 725 1898 .... 1900. 40 65 819 910 1900 and 65 910 after. Before 1900. 186 , 3,025 10,105 251 29 255 3,935 122 HAS SURGICAL TREATMENT LESSENED REPORTS OF ELLIOT CITY HOSPITAL, Keene, N. H. Year. CM O gg 3| H Cases of Appendicitis. Died. 1894 70 73 73 179 142 177 164 193 234 910 394 7 1895 1 1898 8 2 1899 4 1900 5 9 5 5 a 1901 1 1902 1903 1904 8 1 lflOO and after. Ttefore 1900 32 22 2 3 THE MORTALITY FROM APPENDICITIS ? J 23 REPORTS OF THE MERCY HOSPITAL, Spkingfield, Mass. ; Year. Odd ft* "3 e« H Cases of Appendicitis. Died. DO n o t V A o A — 1897.... 1899 408 542 756 1,109 1,152 1,413 1,744 6,274 950 7 28 1 6 2 8 11 7 36 1 7 28 42 60 66 105 168 441 35 142 278 1900. 42 457 1901.... 1902.... 1904. . 61 66 105 380 502 798 1906... 168 563 1900 and 442 2,730 after. Before 1900. 35 420 7,224 477 37 476 3,150 124 HAS SURGICAL TREATMENT LESSENED REPORTS OF CHRIST HOSPITAL, Jersey City, N. J. Year. ft. 2 H Cases of Appendicitis. 3 s Operations. ho i 1892 507 566 741 610 658 875 994 1,171 1,079 3,244 3,957 1 1 8 3 6 15 16 37 12 24 (5 died.) 37 31 97 80 208 61 131 1894 2 5 193 235 1895 11 245 1896 30 307 j 1898.... 1900.... 1901.... 1902.... 1900 and 38 35 ' 89 74 198 447 542 j 670 708 1,820 1.558 after. Before 1900. 87 7,201 285 41) 269 5,378 THE MORTALITY FROM APPENDICITIS ? REPORTS OF BROCKTON HOSPITAL, Brockton, Mass. 125 Year. On fci.2 H Cases of Appendicitis. Died. 6 4 6 7 23 in a S3 a O Total No. of All Ope- rations. 1 boo.... 1901 .... L902.... 1903.... L904.... 292 345 325 325 449 27 24 28 27 60 56 145 34 171 30 171 58 286 67 225 1,736 216 195 998 12(5 HAS SURGICAL TREATMENT LESSENED REPORTS OF CITY HOSPITAL, Haverhill, Mass. Year. 1893. 1894 . 1895. 1896. 1897. o . . QQ 162 169 228 284 804 Cases of Appendicitis. 1 2 5 13 Operations. 1 (0 died.) 1 (1 died.) 4 (1 died.) 10 (2 died.) 7 (1 died.) 16 26 59 68 114 REPORTS OF LEONARD MORSE HOSPITAL, Natick, Mass. 1899, 1901 1902 1903 1905 1906 1000 and after. Before 1900. 86 118 140 145 143 187 733 86 819 6 11 13 25 16 31 86 6 92 5 11 10 23 11 30 85 5 90 55 57 55 63 63 95 333 55 388 THE MORTALITY FROM APPENDICITIS ? 127 REPORTS OF MELROSE HOSPITAL ASSOCIATION, Meluose, Mass. Year. fc.S a & ■ui, Cases of Appendicitis. Died. 1896 136 161 178 196 238 235 283 241 220 231 1,448 671 4 1 1897 10 1898 11 1899 9 1900 12 2 1901 15 2 1902 19 1903 17 2 1904 11 1905 20 1900 and Before 94 4 34 1 2,119 128 5 128 HAS SURGICAL TREATMENT LESSENED o ■-, = ■d c ffl M ft t,. P !> M < £ o a: w H >* OQ w tin O H O w v - '10UI o: ... to • • ■ OS ; ; ; cm HO ■ ... CM • ... IO CO •9D6I O . . . c to • -os • • • 00 IO • • ... ; ; • CN • ; ■ ■ • IO CO : * J? CO - S06t *■ : : • CS -CI ■ • q : 8 : "8+3 h £ o > P«E- Deaths due to Surgical Division. a a c : ** ; c. • T ; "r : ."£ • s* • O'fc .2 K • '+=> » <■ 1 ^ si I o a ft ft \ > \ e Laparotomy and Exploration for Per- Laparotomy for Appendicitis and Strangulated Inguinal Hernia. .. Laparotomy for Appendicitis Recur- Laparotomy Exploration for Ulcera- Tbtal Number of Patients Treated. . . THE MORTALITY FROM APPENDICITIS ? 129 •AOGX "f06I S06T •1061 •2.681 - S6ST CO cc as n-^ic d s; d u u n 03 03 03 a a a 03 03 03 : CCO a a 03 Q3 act ?3 o3 .„ 3 Z*2; a a o 03 03 O S3 a | .2 » g -3 o a! 03 O ~ d : d « .2 • 'E = ° • 2b s ^ • 03 a'^O^.a ■- ; c d„ .~ a a •^r^ ^ a •- • a ' S S 5 .. iWjqB, co co to cc en )4J^> -4-i CO C CO : -3-3 ®-c:s 0;=! ;§3.&a-sa2^^ :> -w +J ^ •*- ,£ — ^ r5 CO > » >- £ d £ a -~ ,a d , ^ fL, g go s Pn <1 CO m j.a'3 a o 5 «tj Hoi .2 d a d - 5| • --°«> § i ? • Mj +i 03 £ « O s- ^ — ' a:^ (h 03 " . ~ • - 3 03 03 :g-2 •■< 71 ~- '» O u . a < c ph p ?h 5 a a a a c« ;rcs .S r i o o =- >- ° >- ^ W « « 03 43 3 o w, • 'Z. '£ a a -^ a «'0 03 0) O 43 3703 aopH^cc&oci M 3 ° CO '^ >^J ■ ._b -~c/3 03 «3 ft S 03 m 03 o a d 52>.ed|og O 03 S-: as HAS SURGICAL TREATMENT LESSENED • rlrt«HH« wwu O^fl.tfc o 5 o a o o «mM N S^SSS.OCC SS H ..j3e3cutB9>.3. to 03 to co oo m q,q/2T« flPSUKS ,£,o,a — .o.^srryaisjescsce&risi -J) a>cv- OctOOOOceajcoKiflKcfiKP.PuiPL, . 5 o— s £ ■£ 3 '£ is CD «j2 c ST >- THE MORTALITY FROM APPENDICITIS ? 131 1 « 1 l' OS I— CO 1 co c- | CO 1 ^ a.iiiujj •h in co io as 1 CO 00 t- I— ■o CO 1 K i-l '006T i O B s.iojag r-1 r-H ^tH rt •aa?jv | I- 00 M j CO i fc pire 006T ddic'-t * 1 2 1 C2 -* CO CO o . fci ES •moi OCiOO: O CO 93 •0061 1 o -r»H o l- d ■* s » CO ■o l- "1 5 Q ajojag " rt •jajjV I ocox O1D0HCS » 1 in M CO H pun 0061 CO CN C3 CO ■[■BlOl lH Co'r-T E> «5_ ° 3 -t' rt c co . 5 —i o S '006T CD iH CO CO I 3 CM ajojag -h" CO 3 s O C *4 t— M • S 5 5 « H t- fc H •006T co_© as oq^c ft "^ " co" 2* aiojsg t- d CO ■* t- -1 "C* O r, h a io c i l-» H uaijv HOCOf-r pire 0061 nmNrtC 5 O « CO ii (1 a S fl ' J C ox'js 4 ' -i - 'Sws | San 3 HOD k -'sp si) c3 cr 3 a •-JiiW CO p. .m . co »„*ai c SX [ 3 03 s-. i 4 5 > < t3 S s-.a St: SgSBS cj © X QQ g '5 c3 J3 Operative Deaths. •3313 -luaojod I OO CO CO ■ 1 !2^« : TBI ox H^Z : •a3B 1 <°. .*» : -liiaDja.I | JTj',; 00 : •0061 I g M f, : aaojag | : •aa« 1 °i l -.' a . : -4U30.13J | g»» : •aa 4 jv 1 S;28 : pu'BOOGT 1 rt : Percentage Relation of Appendicitis Cases to all others. (35 t- w CO CM .. 'ncDT 1 'N -1* CO CM CO * 008 I CI CM C-l -1 -f C* CO 00 CM ^J* •oo6x »*-«>»a •9061 • -CO • Ci ■pouaj a.n+ua O CO 00 U0 CI 1— oc 1- 10 CO 2 *X3 •006T ajojsa: 1C C") CO CO i-i CCt-Ol- CO l-ll-l ^H CO 3 3 C »>* ■»-> d o U3+JV Pub 0061 03 C". — 1 r-< •* CO CO CO CO CO .2 ^ tc" " " " 00 CO U 1— H > Percentage Relation of Appendiceal Operations to All Others. •pOIJ3«J 3ji 4 ua CN CO CI co' ci co' cd CN CO w PQ •0061 .^-: a 2 oaojsg 3 OHrt CO 3 •jajjv pu'B 0061 -t*C75 Cd CO CO id Percentage of Appendicitis Cases Operated Upon. •poua,! a.iiitaa CO 00 CO t- CO ■* -c" io Cl 10 •006T aaojag lOrtO* CO -H CI -1" 00 CM •J3+JV prn? 0061 r.O>C>H 00 CO co t- 00 CO Total Number of all Operations, Major and Minor. •IBaox 29,283 9,217 46,985 22,342 00 O "0061 aiojsfl 15,554 5,356 22,147 14,437 03 PU'B 006T 13,729 3,861 24,838 7,905 CO s s" 132 HAS SURGICAL TREATMENT LESSENED REPORTS OF ST. BARTHOLOMEW'S HOSPITAL, London, England. Year. 1889.. 1890. 1891. 1894. _ +^ ■SPh 6,893 7,160 1892.. 6,123 Casks of Appendicitis. 6,046 1893.. 7,236 6,976 Medical Report : 27 Typhilitis (2 died) Surgical Report : 3 Perityphlitis (0 died) Medical Report : 2 Typhilitis Surgical Report : 4 Perityphilitis and Appendicitis (2 died) Medical Report : 18 Typhilitis (0 died).. Surgical Report : 6 Perityphilitis and Appendicitis (0 died) Medical Report : 34 Typhilitis (1 died) Surgical Report : 5 Perityphilitis and Appendicitis (3 died) Medical Report : 23 Typhilitis (0 died) Surgical Report: 11 Perityphilitis and Appendicitis (2 died) Medical Report : 30 Typhilitis (5 died) Surgical Report : 11 Perityphilitis and Appendicitis (2 died) Operations. 2 (Abdominal Section, 3 died.) (Abdominal Section, died.) 1 (Abdominal Section, 3 died.) 3 I (Abdominal SectioD, 3 died.) 5 1 (Abdominal Section, 4 died.) THE MORTALITY FROM APPENDICITIS ? 133 ST. BARTHOLOMEW'S HOSPITAL — Continued. 1895. 7,290 1896, 7,400 1897 6,918 1898, 6,874 Medical Report : 19 Typbilitis (1 died) 4 Perityphilitic Abscess (2 died) Surgical Report: 12 Perityphilitis and Appendicitis (2 died) Medical Report : 29 23 Typbilitis 6 Perityphilitis by adhesions (2 died) Surgical Report : 52 Perityphilitis and Appendicitis, 6 Mild without suppuration .... 13 Chronic without suppuration . 24 Acute with suppuration (2 died) 6 Chronic with abscess (0 died) . 1 Chronic with Intestinal Stran- gulation by adhesions (1 died) 2 Old Appendicitis with Sinuses (1 died) Medical Report : 37 34 Perityphilitis 3 Perityphilitis with Abscess (3 died) Surgical Report : 48 4 Acute without suppuration. . . 17 Chronic relapsing without sup- puration 23 Acute with suppuration (10 died) 4 Chronic with abscess Medical Report: 30 20 Perityphilitis 2 " with abscess (1 died) Surgical Report : 67 6 Acute without Suppuration . . . 25 Chronic relapsing without sup- puration 31 Acute with Suppuration (8 died) 5 Chronic with abscess 10 10 (Abdominal Section, 3 died.) 43 (14 died.) 1,835 1,971 (9 39 died.) 1,874 59 (15 died.) 2,156 134 HAS SURGICAL TREATMENT LESSENED ST. BARTHOLOMEW'S HOSPITAL — Continued. Year. 1899. 1900, 1901 6,839 6,548 6,587 Cases of Appendicitis. Medical Report : 26 24 Perityphlitis 2 " with abscess (1 died) Surgical Report : 96 16 Acute without suppuration . . . 41 Chronic relapsing without sup- puration 5 Acute Gangrenous (3 died) . . . 26 Acute with suppuration (12 died) 6 Chronic with abscess (2 died) . 2 Old Appendicitis Medical Report : 13 Perityphlitis (0 died) Surgical Report : 107 15 Acute without suppuration. . . 44 Chronic relapsing without sup- puration 6 Acute Gangrenous (4 died) . . . 27 Acute with suppuration (7 died) 13 Chronic with abscess (1 died) . 2 Old Appendicitis Medical Report : 10 Appendicitis Surgical Report : 156 42 Acute without suppuration . . . 48 Chronic relapsing without sup- puration (1 died) 11 Acute Gangrenous (7 died). . . 45 Acute with suppuration (16 died 5 Chronic with abscess (1 died) . 5 Old Appendicitis OrEHATIONS. 90 (16 died.) 89 (12 died.) 121 (25 died.) 2,336 2,140 2,674 THE MORTALITY FROM APPENDICITIS ? ST. BARTHOLOMEW'S HOSPITAL - Continued. 135 1902 6,899 1903 7,117 1905. 7,005 1900 and after. Before 1900 34,156 73,655 107,811 Cases of Appendicitis. Medical Report : 6 Appendicitis Surgical Report: 199 32 Acute without suppuration . . . 98 Chronic relapsing without sup- puration (2 died) 15 Acute Gangrenous (13 died) . . 30 Acute with suppuration (5 died) 12 Chronic with abscess 4 Old Appendicectomy Medical Report : 11 Appendicitis Surgical Report: 204 46 Acute without Suppuration. . , 85 Chronic relapsing without sup- puration (2 died) 15 Acute Gangrenous (11 died) . . 32 Acute with abscess (7 died).. . 13 Chronic with abscess 8 Old Appendicitis — abscess pre- viously opened (8 died) .... 5 Old Appendicectomy Medical Report : 9 Appendicitis Surgical Report : 205 19 Acute Gangrenous (12 died) . . 20 Acute with suppuration (3 died) 38 Acute with abscess (4 died) . . 73 Acute without suppuration . . . 55 Chronic relapsing or quiescent (2 died) 920 614 1,534 2 13 Operations. 171 (19 died.) 3,162 165 (20 died.) '1 11 7 12 3 99 70 169 202 (21 died.) 2,956 2,797 748 219 961 13,729 15,564 29,283 136 HAS SURGICAL TREATMENT LESSENED REPORTS OF WESTMINSTER HOSPITAL, London. Year. 1889. 1890. 1891 1892. 1893. 1894. 1895 H 2,230 2,488 2,296 2,718 2,655 2,756 1,960 Cases of Appendicitis. Medical Report : 8 cases Typhilitis 1 case Perforated Appendix . Medical Report : 6 cases Typhilitis 3 cases Perforated Appendix Medical Report : 5 cases Typhilitis Surgical Report : 1 case Perforated Appendix . Medical Report : 14 cases Typhilitis Surgical Report: 1 case Typhilitis 1 case Perforated Appendix . Medical Report : 9 cases Typhilitis Surgical Report : 2 cases Typhilitis Medical Report : 3 cases Perforated Appendix 12 cases Typhilitis Surgical Report : 1 case Typhilitis 1 case Perforated Appendix. Medical Report : 4 cases Typhilitis 2 cases Perforated Appendix Surgical Report : 1 case Typhilitis Operations. Abdominal Section : 1 (1 died.) 1 (1 died.) (1 died.) Abdominal Section : 1 THE MORTALITY FROM APPENDICITIS ? WESTMINSTER HOSPITAL — Continued. 137 Year. Cases of Appendicitis. •a V s Operations. 6 °£ ■ y.,0 en _ - e . 1,636 844 2,265 2,267 2,085 2,489 140 HAS SURGICAL TREATMENT LESSENED HAMBURGISCHEN STAATSKRANKENANSTALTEN — Cont. YEAR. 1895, 1896. 1897 1898 1899, 1900, 1901 1902, II 9,016 8,787 11,159 23,102 14,763 16,237 16,590 16,390 Cases of Appendicitis. Medical report : 61 cases Perityphilitis . Surgical report : 28 cases Perityphlitis and Appendicitis Medical report : 61 cases Perityphilitis and Appendicitis Surgical report : 29 cases Perityphilitis and Appendicitis Medical report : 158 cases Perityphilitis, Ap- pendicitis and Peritonitis . Medical report : 218 cases Peritonitis and Peri- typhilitis 20 Medical report : 245 cases Peritonitis and Peri- typhilitis 43 46 Medical report : 237 cases Peritonitis and Peri- typhilitis Medical report : 285 cases Peritonitis and Peri- typhilitis Medical report : 214 cases Peritonitis and Peri- typhilitis 50 34 Abscess incised : 4 (1 died.) Abdominal Section : 16. Abscess incised: 2. Abdominal Section : 25 (2 died.) Abscess Incised: 19 (3 died.) Abdominal Section: 27. Abscess incised : 9. Abdominal Section : 27. 70 (8 died.) 11 (9 died.) 78 (15 died.) 124 (18 died.) THE MORTALITY FROM APPENDICITIS ? 141 HAMBURGISCHEN STAATSKRANKENANSTALTEN - Cont. 1903.. 1904.. 1905.. 1906, 1900 and after Before 1900 fcg 9,444 9,619 10,323 11,394 128,997 138,998 267,995 Cases of Appendicitis. Medical report : 292 cases Peritonitis and Peri- typhlitis Medical report : 292 cases Peritonitis and Peri- typhilitis Medical report: 430 cases Peritonitis and Peri- typhilitis Medical report : 520 cases Peritonitis and Peri- typhilitis 2,087 cases Appendicitis 1,310 " " 3,397 " " 40 65 45 47 315 141 Operations. 456 151 (8 died.) 246 (38 died.) 303 (22 died.) 325 (15 died.) 1,304 263 1,567 2,744 3,307 3,350 5,914 24,838 22,147 46,985 U2 HAS SURGICAL TREATMENT LESSENED REPORTS OF ST. THOMAS HOSPITAL, Londox, Eng. Year. 1890 1891 1892-3 1894 4,643 4,667 5,190 5,418 Cases of Appendicitis. 31 Medical report : (28 Perityphlitis — died). . ( 3 Perforative Appendicitis 3 died) 26 Medical report : (24 Perityphilitis — died) . . . ( 2 Perforative Appendicitis — 2 died) 1 Surgical report : (1 died) 28 Medical report : Perityphilitis — (6 died) 3 Surgical report: ( 2 Perityphilitis — 1 died). . . ( 1 Sinus, Perforated Appen- dix — 1 died) 46 Medical report : Appendicitis — (11 died) 3 Surgical report : "Appendicitis " now. ( 2 Recurrent Appendicitis ( 1 Acute Appendicitis — 1 died) 1895 1896 5,755 5,997 44 Medical report : Appendicitis — (10 died). 15 Surgical report : ( 7 Acute — 4 died) ( 7 Chronic — 1 died). . . . ( 1 Sinus — died) 47 Medical report : (12 died). 23 Surgical report : ( 9 Acute — 1 died) (14 Chronic — 1 died). . . . 11 10 5 12 1 c> & « Operations. ir o i- 791 1 Abscess Opened. 2 Lap ar atomy. 2 Incised. 975 1 Laparatomy. 1 Appendicec- tomy. 1,108 10 Incised 2 1,376 7 1,718 22 1,947 36 THE MORTALITY FROM APPENDICITIS ? ST. THOMAS HOSPITAL ~ Continued. 143 6,100 6,140 5,933 5,261 7,038 7,459 19,758 49,844 69,602 No. of Cases Appendicitis. 80 Medical report : (13 died) 22 Surgical report: ( 4 Acute — 2 died) (18 Chronic — died) 72 Medical report: (15 died) 49 Surgical report: ( 9 Acute — 2 died) (47 Chronic — died) 81 Medical report : (8 died) 60 Surgical report : (23 Acute — 6 died) (37 Chronic — died) 72 Medical report : (17 died) 88 Surgical report : (56 Appendicitis — 2 died) (24 " and Abscess — 1 died) ( 8 Appendicitis and General Peritonitis — 7 died) 82 Medical report : (22 died) 110 Surgical report : (66 Appendicitis — died) (36 Appendicitis with abscess — 5 died) ( 1 Local Peritonitis — died) ( 7 General " — 5 died) 110 Surgical report : (14 died) (87 Appendicitis — died) (52 " with abscess — 9 died) ( 6 Appendicitis with local Pe- ritonitis — died) (17 Appendicitis witb general peritonitis — 11 died) 624 636 1,260 13 2 15 2 8 6 17 2 7 22 5 14 11 93 100 193 Operations. 39 75 82 117 146 181 444 282 ^2 - ■33 = - ■— - 2,153 2,242 2,127 2,013 2,609 3,283 726 7,905 14,437 22,342 144 HAS SURGICAL TREATMENT LESSENED REPORTS OF CHARITE HOSPITAL, Berlin. Year. H 1890... XV 1891 ., XVI 1892 . . . XVII 1893.., XVIII 1894 XIX 1895.., XX 1896.. XXI 1897.. XXII 1898.. XXIII 1899.. XXIV 1900 . . XXV 20,308 20,043 20,352 18,919 21,243 20,582 18,832 18,934 18,934 18,284 18,238 Cases of Appendicitis. Medical Report : 45 Surgical Report : 2 Medical Report : 55 Surgical Report : 6 Medical Report : 81 Surgical Report : 5 Medical Report : 42 Surgical Report : 3 Medical Report : 44 Surgical Report : 7 Medical Report : 33 Surgical Report : 1 Medical Report : 28 Surgical Report : 3 Medical Report : 52 Surgical Report : 15 Medical Report : 26 Surgical Report: 7 Medical Report : 46 Surgical Report : 19 Medical Report : 41 Surgical Report: 23 THE MORTALITY FROM APPENDICITIS ? CHARITE HOSPITAL — Continued, 145 Year. o . B'ol OPh H Cases of Appendicitis. Died. 1901 XXVI 1902 XXVII 1903 XXVIII 18,676 18,538 16,804 17,178 16,761 106,190 187,931 Medical Report : 23 Surgical Report : 36 Medical Report : 37 Surgical Report : 38 Medical Report : 49 Surgical Report : 20 1 3 5 1 3 1904 XXIX Medical Report : 44 3 1905 Medical Report : 66 3 Surgical Report : 39 8 1900 and after. Before 1900. 451 (28 died-6.2%) 520 (38 died-7.3%) 294,121 (1 in 302) 971 (66 died-6.7%) 10 146 HAS SURGICAL TREATMENT LESSENED TABLE VII. Showtng increase in mortality of Appendicitis and decrease in Peritonitis from available Census Reports. U. S. Census Report 1900 1904 Report of Registrar General for England and Wales 1901 1906 Deaths per 100,000 popu- lation from Appendicitis. Annario Estadistico de la Republica Oriental del Uruguay, Annos 1904 a 1906 Montevideo 1907 1893 1905 De la Frequence des Principles Causes de De'ce's a Paris 1886-1905 Jaques Bertillon, Paris 1906 (Imprimee Municipale 1886 1894 1897 1900 1905 Statische Jahrbuch der Stadt-Berlin, 1907 Verlagion P. Stankiewicz 1904-5 10.6 12.0 8.8 6.2 Deaths per 100,000 popu- lation from Peritonitis. .4 3.5 1 1 3 6 6 9 1 14.0 15.1 10.1 4.7 2.4 6.4 8.1 11.9 Affections of the Stom- ach except Ulcer per 100,000 popu- lation. 12.3 2.0 THE MORTALITY FROM APPENDICITIS ? 147 TABLE VIII. ROOSEVELT HOSPITAL OPERATIONS. Year. 1873 to 1876 1877 1878 1879 to 1883 1884 ....:.. 1885 1886 1887 1888 1889 Cases of Appendicitis and Nature of Operation. 3 Perityphlitis. 1 Perforation Vermi- form Appendix and Local Perito- nitis, 1 died 3 Perityphlitis. 1 Perityphlitis and Peritonitis, Pleurisy, 1 died Medical Report : 2 Perityphlitis. 2 Incision Perityphlic Abscess a " " 1 « " " 5 ii ic u 3 Incision and Drainage for Perityph- litis 1 Excision of Appendix for Typhlitis . u a a ic ' with Suppurative Peritonitis .... 3 Acute, Excision of Appendix 4 " with Abscess, Excision of Ap- pendix . . 3 « " " Incision and drain- age . ... 3 " " " and General Sup- purative Peritonitis, Excision of Appendix Died. 2 (Moribund on admis- sion.) 148 HAS SUEGICAL TPwEATMENT LESSENED TABLE VIII — Continued. Tear. 1890. 1892, 1893 Cases of Appendicitis and Nature of Operations. 1 Acute, Excision of Appendix, Langenbeck's Incision, no Drainage 3 Acute, with Abscess, Excision of Appendix, Drainage 2 Acute, with Abscess, Appendix not found . 1 Recurrent, Excision of Appendix 1 " with Abscess, Drainage, Apen- dix not found . 1 " " ." Lumbar Incision. 2 Acute, " " Parker's Drainage 1 Perforative General Suppurative Appendi- citis, Median Laparotomy 1 Acute Abscess, Inguinal Hernia 14 Acute with Abscess, Excision of Appendix, Drainage 5 Acute with Abscess, Drainage of Appendix not removed 4 Recurrent Interval Excision of Appendix . . 5 Sinus following Appendicitis 4 Fecal Fistula following Appendicitis 12 Acute with Abscess, Appendix not removed 8 " Appendix excised 1 " General Peritonitis, Appendix Ex- cised 2 Gangrenous, Appendix Excised, Drainage . 1 Perforative, Septicaemia 2 " General Peritonitis 8 Relapsing in Interval, no Drainage 4 " " " Partial Packing.. . 2 Sinus after Appendicitis 1 Lumbar Drainage after Appendicitis. 2 Recision, Appendicitis Wound Died. (Peritonitis.) (General Septic Per- itonitis. 1 (General Peritonitis.) (On second day, Sep* ticaemia.) 1 TV: (Valvular.) 1 (Shock.). 1 (Shock.) 1 1 1 (Valvular.) THE MORTALITY FROM APPENDICITIS ? TABLE VIII. — Continued. 149 Cases of Appendicitis and Nature of Operations. 14 Acute with Abscess, Appendix not removed . 11 " " " " excised . . 2 " without " " " 7 " General Peritonitis, Appendix excised . 1 " " " " not " 5 Relapsing, Interval, Usual Incision, No Drainage 2 Relapsing, in Interval, Usual Incision, Partial Drainage 9 Relapsing, in Interval, McBurney's In- cision, No Drainage 2 Relapsing, in Interval, McBurney's In- cision, Partial Drainage 1 Supposed Acute Appendicitis, Laparatomy negative 1 Secondary Abscess following Acute Appen- dicitis 1 Chronic Abscess following Acute Appen- dicitis 3 Fecal fistula following Acute Appendicitis (same case) , . . . . 8 Recision of Appendix wound 18 Acute, Removal of Appendix 10 " Abscess, Incision and Drainage 1 " with progressive Peritonitis, remo- val Appendix, Drainage 6 " with General Peritonitis 1 Subacute 2 Relapsing, Removal of Appendix 14 " " " McBurney's incision 1 Relapsing, Removal of Appendix, Drainage . 5 Chronic " " 1 " Abscess. Removal of Appendix . . . 1 " Enterorrhaphy, Removal of Ap- pendix 1 Abdominal pain, Exploratory laparatomy and removal of Appendix 1 Pain following Appendicitis, Exploratory laparatomy Died. 150 HAS SURGICAL TREATMENT LESSENED TABLE VIII. — Continued. Teak. Cases of Appendicitis and Nature of Operations. 1895.. (Cont.) 1896. 1 Sinus following Appendicitis operation, Appendix and Sinus removed 2 Recision of Appendicitis wound 1 Abscess (not found) following Appendicitis operation 3 Sinus following Appendicitis operation, Recision 1 Sinus following Appendicitis operation, Enterorrhaphy 1 Sinus following Appendicitis operation, Rectal Drainage 3 Fecal fistula following Appendicitis opera- tion, Recision 11 Acute, Removal of Appendix Drainage... . 1 " " " " McBurney's method 1 " closure 25 " Incision and Drainage, Abscess .... 1 " " " " " En- terorrhaphy 5 " progressive Peritonitis, Removal Appendix, Drainage 1 " localized Peritonitis, Incision and Drainage 4 " general Peritonitis, Removal of Appendix, Drainage 2 Subacute Removal of Appendix, McBur- ney's method 1 " Incision of Abscess, Drainage . ... 15 Recurrent, Removal of Appendix, McBur- ney's method 2 " Removal of Appendix, McBurney's method 1 " Abscess Incision and Drainage .... 1 " and Dermoid of Ovary 3 Chronic, Removal of Appendix 5 " " " McBurney's method 1 Exploratory laparatomy for pain, Appendix removed Died. THE MORTALITY FROM APPENDICITIS ? TABLE VIII — Continued. 151 Cases of Appendicitis and Nature of Operations. 1 Localized Peritonitis following Appendix operation. Laparatomy and Drainage . . . 1 Septic Peritonitis following Appendix ope- ration Drainage 1 Abscess, Old Appendicitis 3 " secondary to Appendix operation, Incision Drainage 1 Adhesions 2 Sinus 1 Fecal Fistula 2 Acute, Removal Appendix, Drainage. . . 2 " " " McBurney's method 37 " Incision and Drainage, Abscess.. 6 " and progressive Peritonitis. Removal Appendix 7 " General Peritonitis . 1 Recurrent, Removal of Appendix 36 " " " McBurney's method .... 2 Chronic, Removal of Appendix 4 " " " McBurney's method 1 Abscess secondary to Appendix operation, Incision and drainage 1 Adhesions secondary to Appendix operation . 1 " Intestinal obstruction 1 Recurrent with Nephroptosis 3 Acute (during attack), McBurney's oper- ation (Intermuscular Appendicectomy. . 1 Acute (during attack), Appendicectomy and Drainage 24 Acute Abscess, Appendicectomy and Drainage 6 Acute Abscess (appendix organized), Ap- pendicectomy and Drainage 10 Acute Gangrenous, Septic Peritonitis, Ap- pendicectomy and Drainage 152 HAS SURGICAL TREATMENT LESSENED TABLE VIII— Continued. Year. Cases of Appendicitis and Nature of Operations. Died. 1898.. (Cont.) 2 Acute Abscess, Progressive Peritonitis, 3 Acute Abscess, Sepsis, Appendicectorny and Drainage 3 3 Abscess, secondary to Appendix operation, Appendicectorny and Drainage 1 Recurrent during attack, Appendicectorny Intermuscular 32 Recurrent, interval, Appendicectorny In- termuscular 6 Recurrent, interval, Appendicectorny 6 " and Abscess, Appendicectorny and Drainage 4 Recurrent, and Abscess, Appendicectorny and Drainage (Appendix disorganized) 1 Recurrent, with Progressive Peritonitis . . . 1 Chronic Abscess 1 1 1 1 1 Recurrent and Endometritis 1 Abdominal Colic (Appendicitis ?) Explor- atory Coeleotomy 1899.. 1 Acute (during attack), Appendicectorny (Intermuscular) 4 Acute, Appendicectorny Drainage. ....... 35 with Abscess, " " 1 " " and Progressive Focal Peri- tonitis, Appendicectomv Drainage 1 with General Peritonitis, Miscarriage, Sep- ticaemia 5 1 8 Acute Gangrenous, General Septic Peri- tonitis 4 1 Secondary Subphrenic Abscess 1 Suppurative Mesenteric Odenitis 1 1 Multiple Sinuses, Abdominal Wall, follow- ing; Acute Appendiceal Abscess 57 Recurrent, Appendicectorny Intermuscular 1 (Fecal Fistula.) (Died Inanition.) THE MORTALITY FROM APPENDICITIS ? TABLE VIII — Continued 153 Cases of Appendicitis and Nature of Operations. 5 Recurrent, Abscess 1 Intestinal Paresis, following operation, as- piration of feces through old coeliotoray wound 8 Chronic, Appendicectomy (Intermuscular) 1 Chronic Abscess 1 " breaking up adhesions 1 broken Drainage Tube in Pelvis, following operation for Appendiceal Abscess 49 Recurrent Appendicectomy (Intermuscular) 24 Gangrenous and General Peritonitis, Ap- pendicectomy and Irrigation-Drainage. . 24 Acute Abscess 1 Secondary Retrocecal Abscess, following Appendiceal Abscess, counter Drainage in flank, curetting old sinus 1 Subacute, lumbar incision , 1 Acute Gangrenous, with General Septic Peritonitis, Appendicectomy and Drain- age .•••;:• 2 Acute Gangrenous, with Local Peritonitis, Appendicectomy and Drainage 10 Interval (Intermuscular incision) 2 Acute, Appendicectomy and Drainage . . 2 Recurrent and Abscess 7 Chronic, Appendicectomy (Intermuscular). 1 Chronic and Intestinal Adhesions, Appen- dicectomy and Enterorrhaphy. 1 Chronic and Abscess, counter opening flank 3 Secondary Abscess, following operation, Gangrenous Peritonitis and General Peritonitis 8 Suppurative Appendix, Sinus 1 Fecal Fistula, following Appendiceal Ab- scess, Enterorrhaphy (Fecal Fistula.) (Died Inanition.) 1 (Sepsis.) 13 2 154 HAS SURGICAL TREATMENT LESSENED TABLE VIII — Continued. Year. Cases of Appendicitis and Nature of Operations. Died. 1901.. 40 Recurrent, Appendicectomy(Interrnuscular) 2 Catarrhal, " " 8 Gangrenous, " Drainage-Irrigation g U U It i. General Peritonitis 1 (Delirium Tremens 2 2 5 1 1 5 6 4 8 ) 43 Acute, with Abscess, Ap23endicectomy- DrainaEfe-Irriofation 2 Acute, with General Peritonitis, Appen- dicectoruy-Drainage-Irrigation. 1 Chronic, with Tubercular Peritonitis, Ap- pendicectomy (not drained) Irrigation . 1 Chronic, with Floating Kidney 5 Chronic, Appendicectomy (Intermuscular) 1 " with Retroverted Uterus, Appen- dicectomv (Intermuscular) 1902.. 20 Acute Catarrhal Appendicectomy 10 " with Spreading Peritonitis Appen- dicectomy no Drainage 7 Acute with Spreading Peritonitis Appen- dicectomy Drainage 53 Acute with Abscess Appendicectomy Drainage 7 Gangrenous and General Peritonitis Ap- pendicectomy Drainage 35 Chronic Appendicectomy 37 Recurring; 4 Chronic with Ovarian cyst 1 " " Fistula 1903.. 1 " " Femoral Hernia 1 " " Retroversion of Uterus 1 Adhesions about Appendix: 45 Acute, Appendicectomy 46 " with Abscess, Appendicectomy and 1 Appendicular Colic 18 Acute with Spreading Peritonitis Appen- dicectomy and Drainage THE MORTALITY FROM APPENDICITIS ? TABLE VIII — Continued. 155 Year. Cases of Appendicitis asd Nature of Operations. Died. 1903.. (Cont.) 6 Acute with Spreading Peritonitis Closed and Drainage 1 4 Gangrenous with Spreading Peritonitis . . . 1 With Strangulated femoral Hernia, Ap- pendicectomy and Bassini's Operation . . 1 Chronic with Tuberculosis of Mesenteric Lymph Noves 1 Appendicostomy 2 3 Acute with Acute Salpingitis 1 Retrocecal Abscess after Appendicectomy . 1 Sinus following Appendicectomy ; Lapara- tomy and Resection 8 inches of Caecum Dr.Chas. McBurney appointed April 1, 1888, to succeed after resignation of Dr. Henry B. Sands, Dr. McBurney, in 1900 report resigned. 1904, 45 Acute Appendicectomy 35 " with Abscess Appendicectomy and Drainage 9 Acute with Spreading Peritonitis Appen- dicectomy and Drainage. 21 Acute with Spreading Peritonitis Appen- dicectomy no Drainage 9 Acute with General Peritonitis Appendi- cectomy and Drainage 92 Chronic. 4 Acute with Abscess Drainage, Appendix not Removed 1 Sinus following Appendicostomy, Appen- dicectomy 1 Perityphilitis and Inverted Appendix Ap- pendicectomy and Colotomy 1 Chronic with Actinonycosis of Caecum, Resection of Caecum 1 Fecal Fistula Enterororrhaphy 1 Acute with Intestinal Obstruction, Appen- dicectomy and Enterolysis 156 HAS SURGICAL TREATMENT LESSENED TABLE VIII- Continued. Yeak. Cases of Appendicitis and Nature of Operations.' Died. 1905 1 38 " with Abscess Appendicectomy and Drainage 1 1 Acute with Abscess and Spreading Peri- tonitis Appendicectomy and Drainage . . 8 Acute with Spreading Peritonitis Appen- dicectomy and Drainage 1 14 Acute with General Peritonitis Appendi- cectomy and Drainage 7 2 6 Gangrenous Appendicectomy and Drainage 1 " with General Peritonitis (No 1 35 Catarrhal Appendicectomy 1 1 Tuberculous Exploratory Laparatomy 1 Appendicitis with Salpingitis, Appendi- cectomy and Salpingectomy 1 Appendicitis with Pelvic Abscess Perineal Drainage 1 Appendicitis with Tubercular Peritonitis, Appendicectomy 1 Abscess of Appendix, secondary, Rammer's 1 Abscess of Appendix, Old Appendicectomy and Drainage 1 3 Abscess of Appendix, Median Incision and Drainage 1 Hydrops of Appendix, Appendicectomy. . 1 Pain of Appendiceal Stump Laparatomy and Incision of Stump 1906.. 1 Appendicular Colic Appendicectomy 2 Interval Appendicectomy < 74 Chronic " 1 51 Acute " 49 " with Abscess Appendicectomy and Drainage 2 2 Abscess secondary to Appendicectomy In- cision and Drainage 4 Appendicitis with Spreading Peritonitis, 2 THE MORTALITY FROM APPENDICITIS ? TABLE VIII — Continued. 157 Year. Cases of Appendicitis and Nature of Operations. Died. 1906.. (Cont.) 6 Appendicitis with Spreading Peritonitis, Appendicectomy and Drainage 1 Appendicitis with Spreading Peritonitis, Subphrenic Abscess, Empyaema Ap- pendicectomy and Drainage Incision and Drainage of Abscess, Resection of Rib . 8 Appendicitis with General Peritonitis, Ap- pendicectomy 6 Appendicitis with General Peritonitis Ap- pendicectomy and Drainage 1 Appendicitis with Adenocorcinoma of Per- itoneum Appendicectomy 158 HAS SUEGICAL TREATMENT LESSENED TABLE IX, ST. BARTHOLOMEWS HOSPITAL OPERATIONS. Tear. 1888, 1889. 1890. 1891. 1892. 1893. 1894. 1895 . 1896. Cases of Appendicitis and Nature of Operations. 9 Abdominal Sections for Acute Peritonitis ] Excision of Vermiform Appendix 5 Abdominal Sections for Appendix and Peritonitis 1 " " " Typhlitis 4 " " " Appendicitis 6 " " " Suppurative Peritonitis 6 " " " Appendicitis ^Q a ■ u u a 7 Acute with Suppuration, Appendix removed, Irrigation, Drainage 3 " " " " not removed, Irriga- tion 13 " " " " not removed, limited incision through per. adhesions 2 " " " " not searched for, no Irrigation, simple Drainage 2 " " " " removed, limited In- cision through per adhesions 6 Chronic with Suppuration, Appendix not searched for, limited incision through per. adhesions 8 Chronic Recurrent without Abscess, Appendix removed . 1 Acute with Strangulation of Intestines by Adhesions, Appendix removed 1 Old Appendicitis with Sinuses, removal of Appendix and foreign body THE MORTALITY FROM APPENDICITIS ? TABLE IX — Continued. 159 Cases of Appendicitis and Nature of Operations. 1 Acute without External Suppuration, Exploratory Incision 2 Acute with Suppuration, Appendicectoniy, Irrigation, Drainage ' " " Appendicectomy, Irrigation, no search for Appendix, ' " ' : no search for Appendix, sim- ply Drainage, no Irrigation ' " " Local Sponging, no search for Appendix ' " " Limited Incision through per. adhesions, Appendix not removed 2 Chronic with Abscess, Appendix removed, Local Spong ing, Drainage 1 " " " Limited Incision through adhesion no search for Appendix. 13 Chronic Recurrent without External Suppuration, Appen dix removed. 3 Acute without External pus-Exploratory Incision ' " " " Appendicectomy-Irrigation- Drainage " " " Irrigation, no search for Appendix • " " "no Irrigation, no search for Appendix, simply Drainage ' " " " Appendix removed 1 " " " " not removed, limited Incision through Peritoneal Adhesions 5 Chronic with Abscess, Appendix removed 21 " without External Suppuration, Appendix removed 1 " Concretion removed 1 Acute without External Suppuration, Exploratory Incision 2 " " " " Appendix removed . . 3 " with Suppuration, Appendix removed, Drainage.. . 24 " " " Appendix not searched for Drainage. Died. 160 HAS SUKGICAL TREATMENT LESSENED TABLE IX. — Continued, Tear. 1899.. (Cont.) 1900 1901.. 1902.. Cases of Appendicitis and Nature of Operations. 3 Acute Gangrenous, Appendicectomy, Drainage 1 " " Peritoneal cavity washed out, but no search for Appendix 1 " " no washing, Simply Drainage, Ap- pendix not searched for 2 Chronic with Abscess, Appendix removed 4 " " " no search for Appendix 36 " without External Suppuration, Appendix removed 1 " " " " limited incision through adhesions, no removal of Appendix . . 1 Old Appendicitis, Removal of Stitch 1 Removal of Appendix for Hernia 1 Acute without External Suppuration, Exploratory incision 5 " " " " Appendix removed . . 9 Acute with suppuration, Drainage, Appendix removed. . . 17 " " " " but no search for Ap- pendix 5 Acute Gangrenous, Drainage and Appendix removed .... 1 " " Appendix not searched for ... 8 Chronic with Abscess, Appendix removed 5 " " " " not " 1 " Recurrent without External Suppuration, Explor- ratory incision 36 " Recurrent without Appendix removed 1 " « " " not " limited in- cision through adhesions 1 removal of Appendix for Hernia 21 Acute without External Suppuration, Appendix removed. 4Q u a u u u a 1 Acute Gangrenous, Drainage, no search for Appendix. . . . 10 " " " and Appendix removed. . . . 11 " with suppuration " " " " .... 34 " " " " but no search for Appendix . 2 Chronic with suppuration, Appendix removed 3 " " " Drainage, but no search for Ap- pendix 1 Incision of Actinomycosis . . . . . 1 Removal of Appendix for Carcinoma Til E MORTALITY FROM APPE N I ) I C] TI S ? TABLE IX. — Continued. 161 Year. 1902.. (Cont.) 1903.. 1905.. Cases of Appendicitis and Nature of Operations. 1 Removal of Appendix for Tubercle 16 Acute without External Suppuration, Appendix removed . 2 " " " " Exploratory incision. 93 Chronic, Removal of Appendix 4 Acute Gangrenous, Drainage, no search for Appendix . . 9 " " Appendix removed and Drainage .... 14 " with Suppuration, Appendix i*emoved 15 " " " Drainage, no search for Appendix 2 Chronic with Abscess, Appendix removed, Drainage 10 " " " Drainage, no search for Appendix . 6 Old Appendicitis, Appendix removed 21 Acute without External Suppuration, Free Incision and Appendix removed 75 Chronic relapsing without Suppuration (External) Ap- pendix removed 1 Acute Gangrenous, Drainage, no washing or search for Appendix 13 Acute Gangrenous, Appendix removed 10 Acute with Abscess, Appendix removed, Drainage 24 " " " Incision and Drainage, but no search for Appendix 3 Chronic " " Incision, Appendix removed 10 " " " no search for Appendix 1 Old Appendicitis, Removal of Appendix 6 " " Incision Abscess 21 Acute Gangrenous, Removal of Appendix, Drainage. . 36 Acute with Abscess, Free incision and Drainage 21 " " Suppuration, Removal of Appendix 42 " without " " " " 69 Chronic, relapsing or quiescent, Removal of Appendix 2 Appendicectomy for abdominal pain 14 2 1 10 162 HAS SURGICAL TREATMENT LESSENED < s 1 t~ CD -* CO ^ T"H co CO CO iG 1 C5 CO C6 TH -* J sq^a-a ■* GO t- co f ^tf *C 1— CO GO t- ■*H oc H jeqrariK: t-_ "-J. 6^ o O o O tH OOt-hcMOOOOt-hO o 1 o Q o sq^aa 01 -* lO ^J CD n-*O«000-*0t- CO T-l ITS o £- Oi t- CO O OOOOOOCO'tOlOtS o CO 00 CJ 00 t^ O cn O r- c- io co 10 Oi co co -* os O isqtnnjsi CM o t- !- 1 ffl NMO i-l CN-*O00 IO t- Oq -* o 1-1 -* ta C0 # co o: # CM o tH l£S *s> 1C t- 1-H ■* -) -st o sqi-eaa •<* CO t- o CO r- t- CO CO rH 00 »o OJ 30 -T jaqranji C» f; CO *"i. CO Q i— < ■a O pei^-oclo % OS OS C5 * S£ oS ftp t- © CD 0) o CO CD Mot co "" . j> o i> O > c M i .2 2~ OJ "r; t-h ■^H co OS •£ 1-H CO 1 S3 So r w ^S- S = - Z i 3 ofe g><» . -u * be oo _; . * c a S s ^ ©-a Ph OJ /- S-M C3 C i-l l—l w B n IT! Ph 3 M 0j~ r- ® 2 O c > -(-> a CJJ 73 03 o *r< 5z > I CD tj'p o Ph 3 O > >H cf C P_i bJD O +3 03 r£ r? a r e OS c ft M O OS a a CO O M - 5 B .> CD a cci O - " +=> -i3 i—3 - c .- CO <»,-H f. ®1 CD c ^ 'c CD r 5 i O J 03 U2 lH 1 .02 ,Jh C -u CO CO o be O S3 . C > i B. > c 1 o-i: j a ) .i -i- ; £ j s o S&o ^W i_q THE MORTALITY FKOM APPENDICITIS ? 1 TABLE XL Showing fatality and percentage of cases operated in the U. S. Public Services. Years. Cases. Operations FOR Appendicitis DIED. Total All Oper- ations. Navv 1901-1907 1895-1907 1898-1906 785 647 1,915 478 (60%) 295 (45%) 57% for years 1905-6 12 (1.5%) 55 (8.5%) 93 (4.8%) 6,981 Marine Hospital 15,964 3,347 About 50% 160 (4.7% Mean Annual 65,000 plus. Total number of cases of Appendicitis treated in U. S. Naval Hospitals from 1901 to 1907. inclusive.* Year. Cases. Operations for Appendicitis. Died. Total Operations for All Causes. 1901 1902 1903.... .. 1904.. ..... 1905 1906 1907 51 72 88 '99 141 157 177 25 (1 died.) 42 38 (1 died.) 67 (1 died.) 110 93 103 2 3 2 3 2 345 662 753 1,022 1,533 1,502 1,164 (list incomplete.) 785 478 (60%) 12 (1.5%) 6,981 ♦Furnished through the kindness of the Surgeon General. 164 HAS SURGICAL TREATMENT LESSENED TABLE XI — Continued. ANNUAL REPORT OF PUBLIC HEALTH AND MARINE HOSPITAL SERVICE. Year. Cases. Died. Operated for Appendicitis. Total Operations. 1895 1897 6 34 39 29 47 50 38 48 80 72 110 94 589 108 3 4 5 6 3 7 5 4 8 5 4 1 37 18 4 (2 died.) 18 (2 died.) 12 (2 died.) 15 (2 died.) 17 (3 died.) 43 (5 died.) 33 (3 died.) 32 (3 died.) 58 (1 died.) 63 261 (48%) 34 (31%) 998 903 1898 1 121 1899 1,110 1,372 1,385 1,178 1,385 1900 1901 1902 1903 1904 1905 1906 1.529 1,564 1,648 1907 1,821 Before 1900 647 55 (8.5%) 295 (45%) 15,964 REPORTS OF THE SURGEON GENERAL OF THE U. S. ARMY. 1898 1904 1,394 230 291 71 12 10 1905 1906 120 (9 died.) 183 (8 died.) 3,004 3,189 1,915 93 (4.8%) THE MORTALITY FROM APPENDICITIS ? lt)5 TABLE XII. SUMMARY. CO c-6 bo Unopekated. 6 tn u oS 0) c3 o H a) a +3 >» - t- 5 — o oS cu OS 6.6 u o CO Cases. % Fatality. Present Essay. 1870-90. 1,916 Negligible. 1,919 6.6 (Died, 128.) Sahli 1890-95. 7,213 (Died, 692.) 6.5 9.7 6,740 8.8 Strieker 1880-00. 6,296 (Died, 207.) 3.7 4.2 6,061 O . it Strieker 1900-05. 4,498 (Died, 142.) 14 3.1 3,869 1.1 Present Essay. 1905-05. 971 31. 6.7 (Charite, Ber- (Died, 66.) (Approxi- lin.) mately.) PresentEssay. 1890-07. 34,654 (Died, 2832.) 85. 8.1 Present Essay. 1890-07. 15,003 (Died, 1192.) Probably more than 70. 7.9 PresentEssay. 1895 to (Public Servi- 1907.... 3,347 Over 50. 4.7 ces.) (Died, 160.) RD542 V?3 Vale Has SUrffioal +.T»r>«+.Tn»n-h loseanuH + !->< COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 542 V23 C.1 Has surgical treatment lessened the mort 2002252449