f
disturbance of his general nervous system. By this time he may be
attacked with intense pain in the part of his abdomen a little above the
middle of the right groin, and at that spot there may be a tenderness,
and a feeling of resistance may be made out by the gentle pressure of
the finger. In order to relax the pressure upon the tender area he
probably lies with his right thigh slightly bent. By this time he may
look ill, his face being slightly flushed, or pale and anxious. If the
clinical thermometer is placed under his tongue, the index may rise a
degree or two, perhaps several degrees, above normal, and his pulse may
be quickened to 90 or 100 beats a minute. Perhaps it is a good deal
quicker than this. Later, the skin of the lower part of the right side
of the abdomen may be flushed or reddened.

This clinical picture leaves no room for doubt. The boy has an attack of
acute septic inflammation of his appendix. Let it be that the symptoms
have come on quickly, and that the affection is not more than ten or
twelve hours old; no one can tell precisely what course the disease is
going to run. It may be that with rest in bed, constant fomentations,
and absolute starvation, the inflammation will subside; but it is just
as likely that in spite of this judicious treatment the symptoms will go
from bad to worse, and that a belated operation will fail to rescue the
boy from a general peritonitis which may end fatally. But at present, so
far as one can tell, the disease is still limited to the appendix. And
what, at this moment, is the best line of treatment? Some practitioners
would answer--"Let the acute attack settle down, and then, after a week
or ten days, when everything is quiet, remove the appendix, for
statistics show that when the operation is done in the quiet interval
the results are extremely favourable, whilst if it is done in the acute
stage the outlook is not so bright." This is quite right. But one cannot
be sure that the "quiet interval" will ever arrive. The case in question
may be one of those which rapidly go on from bad to worse, and
mortification and perforation of the appendix having taken place over
some hard faecal concretion, general peritonitis is inevitable, with
distension of the bowel and hopeless blood-poisoning. If it were certain
that the attack of appendicitis would subside and become quiescent, it
would be wise to wait. But it too often happens that the first attack
is, indeed, the last.