esult could have been expected. It was not to the
operation, but to the intensely acute disease that the calamity must be
attributed.

Nature is marvellously clever in some of these cases in shutting off the
area of the disease by glueing together the neighbouring coils of
intestine, the limited local peritonitis causing the tissues to build
themselves into a wall which securely shuts in the abscess cavity. But
in other cases she seems helpless, no barrier being formed for limiting
the area of disturbance. In such a case it is inevitable that
disappointment must result from the surgeon delaying operation in the
hope that delimitation might take place. And when at last he makes his
incision he sees that the disease has had so long a start that his own
chance of success is but a poor one. In a less severe attack, under the
influence of rest, starvation and fomentation, and in cases of chronic
and of relapsing disease, the surgeon may watch and wait and choose his
own time for operating. But when the symptoms are steadily increasing in
severity he should urge an immediate incision. When, as often happens,
the inflammation begins suddenly and severely, and, under the influence
of treatment, steadily quiets down, the surgeon does well to delay
operation. But in a fortnight or so, when everything has become once
more quiet, he will urge the removal of the appendix, for this one
attack is more than likely to be the forerunner of other attacks if the
diseased appendix is left.

The most serious cases are those in which the aspect, the pulse, and the
temperature of the patient fail to give warning of a very advanced state
of disease. Every surgeon of experience has met with cases in which,
though there is nothing pointing to the fact that the patient is on the
brink of a disaster, the operation has shown that the appendix is
mortified, and that it is surrounded with abundant foul matter. It is
then that he regrets not having operated a day or two earlier.
Consequently it is a good rule to operate in all doubtful cases. In
cases in which one happens to know that previous attacks have passed off
under palliative treatment, there is no need for immediate operation;
the quiet interval may be safely waited for. But in cases in which there
is "no history," and in which the surgeon has nothing to guide him, the
greatest safety is in prompt operation.

If an attack of acute appendicitis is allowed to take its course
unoperated on, ab