Acute Appendicitis: *

An Analysis of 1,662 Consecutive Cases

J. REED BABCOCK, M.D., F.A.C.S., WILLIAM MARK MCKINLEY, M.D.

Danville, Pennsylvania

IntroductionACUTE APPENDICITIS continues to be the

most common major surgical emergency.Yet, uncomplicated cure has become soroutine that the consequences of late orimproper management are infrequently con-sidered. The general means by which thepresent, nearly satisfying, results of treat-ment have been obtained are accepted tobe timely diagnosis, proper precise surgery,and the use of effective therapeutic ad-juvants. However, the exact roles and rela-tive values of these factors continue to beabstruse.The purpose of this paper is to evaluate

critically all cases of acute appendicitistreated in the Geisinger Memorial Hospitaland Foss Clinic during the past 20 years.By so doing it is believed that the factorswhich have determined success or failure intreatment can be identified. In particular,it is hoped that a more precise understand-ing of the role of one of these factors,namely the antibiotics, may be gained.From the beginning of this study it was

realized that the stability of certain factorsin our institution would facilitate this anal-ysis. Foremost was the fact that there wasthroughout the period in study a uniformconcept of treatment-all cases of suspectedacute appendicitis were operated upon andin each the offending organ was removed.Preoperative suspicion of perforation or evi-dence of abscess or peritonitis did not alterthis concept. Operative therapy in the faceof suspected perforation was not routinely

* Submitted for publication August 15, 1958.

practiced in many institutions during thetime considered in the first part of thisstudy. As a result of our standardized ap-proach, one confusing variable-that ofchanging indications for operation-was notpresent.The constancy of other factors was ap-

preciated. Since this is a closed staff hos-pital the operations were performed by alimited number of surgeons. There was,accordingly, considerable standardizationof operative technic and of postoperativecare. At operation a right lower pararectusincision was the rule. The appendicealstump was closed with a nonabsorbableligature and not inverted. Rubber tube orlatex drains were placed in the retrocecalspace and pelvic cavity when pus waspresent.

Method of StudyAll cases of appendicitis treated at the

Geisinger Memorial Hospital and FossClinic from January 1, 1936, to December31, 1955, were reviewed. In each the diag-nosis was confirmed histologically exceptin instances in which the appendix hadsloughed and was not obtainable. Cases inwhich appendiceal inflammation was pres-ent but not the primary pathologic processwere excluded. Thus certain patients withperforating neoplasms of the appendix oradjacent bowel, ileocolic intussusception,strangulated hernia, and pelvic infectionwere not considered.The records of 1,662 patients were finally

accepted. This figure represented a yearlyaverage of 83.1 patients and included ex-

131

132TABLE 1. Acitie Appendicitis at Gei

AMemorial Hospital-Foss Clin

Period I (1936-40)Period II (1941-45)Period III (1946-50)Period IV (1951-55)

Total

tremes of 57 in 1943 and 117 i]each case the significant historicaand pathologic aspects togetherclinical course and result wereGenerally the factors consideredpared in regard to five-year perarbitrary grouping served to siIpresentation. Where elucidativeages rather than abstract numused. The number of cases in eacperiod is shown in Table 1. Anumber were treated in each perinsignificant figures for analysis.

Age and Sex

No child less than one year otreated. There were three cases band 24 months of age, all girls.

BABCOCK AND MC KINLEY Annals of SurgeryJuly 1959

isinger of this disease during the first two years oflife has been reported. Considering children

No. of Cases two years of age or less Snyder and Chaffinnoted the disease in only 21 of approx-

382 imately 25,000 admissions (of that age560 group) to the Los Angeles Children's Hos-401 pital. Abel and Allen' in reviewing 1,165

1)662 cases in children (0 to 12 years) encoun-

tered only two cases (0.17 per cent) occur-ring during the first year of life. Hawk,

n 1948. In Becker, and Lehman' reported that theirL1, surgical, youngest patient in 1,003 cases of acute ap-with the pendicitis was five months of age. Possiblerecorded. explanations for such a low incidence in-were com- clude the infrequency of respiratory infec-iods. Such tions in this age group, the configuration ofmplify the the organ during early life, the diet, and the, percent- limited ambulatory status of the patient.bers were Seven cases were found in patients in theh five-year ninth decade (80 to 89), four of whomsufficient were male and three female. The five-year

od to yield period age by decade correlation is shownin Figure 1 and illustrates the relative fre-quency of the disease in the second andthird decades. Despite the well-known gen-

f age was eral aging of the population no significantetween 13 increase in the disease in the later decadesThe rarity occurred. McIver,7 however, did report an

ACUTE APPENDICITIS

INCIDENCE RELATIVE TO AGE IN SUCCESSIVE FIVE YEAR PERIODS

NUMBEROF

CASES

150-

50-

D}CAIE - 1 2 3 4 5 6 7 8 9

PERIOD I(1936-40)

F L11

2 3

PERIOD II(1941-45)

FIGURE 1.

/

V2 3

PERIOD M(1946-50)

.

PERIOD IV(1951-55)

;-7

7

ACUTE APPENDICITIS

increasing incidenice of appenldicitis in theolder age grouips.

Duration of Symptoms

Each case was studied in regard to theduiration of symptoms. The time accordingto history when the patient first complainie(dof abdominal paini, nauisea, v-omiting, diar-rlhea, fever, oI uIrinary disturbance wN as

noted except in a fews cases when therecorded history was unrevealing. The cases

wvere grouiped ieferable to duratioin of svimp-toImls prior to admission to the hospital as

shown in Figure 2. The lack of change insuccessive five-year periods is remarkable.Some studies (Slatterv 10 et al., Abel andAllen 1) have reported lessening of thesy7mptom duration before hospitalizationand have concluded that such was an im-portant factor in reducing the morbidityaind mortality of appendicitis. Cantrell,4 in

ACUTE APPENDICITIS

DURATION OF SYMPTOMS PRIOR TO ADMISSION

(SUCCESSIVE FIVE YEAR PERIODS)150 -

100 -

U

I).

0Ut

hW

z50-

PERIOD I

(1936-40)

PERIOD

(1941-45 )

FIcUH 2.

agreemenit with uis, fouind no imnprovementin this regard.The duration of synviptomns prior to ad-

mission in patients with perforated appen-dices wvas noted (Fig. 3) and emphasizedthe rarity of perforation in patients withsymptoms existent for 12 or less hours. Inthe entire series, 397 patienits wvere admitte(lwith symptoms of such brief duration. Ofthese only 175 had appendiceal perforationat the time of operation.

WN'hen dur ation of symptoms wN-as conI-sidered in respect to mortality (Fig. 4) itwas found that in the entire series no

deaths related to infection occurred in pa-tients admitted within 12 hours from thetime of onset of symptoms. Comparing Fig-ures 2, 3, and 4 it can be seen that mostpatients were admitted between 13 and 24hours from the time of onset of symptoms.Patieints fouind to have perforation were

more often admitted N-ith symptoms of 25

zPERIOD III(1946 -50)

PERIOD IV(1951-55)

\olume 150Nunibcr 1 133

134 BABCOCK ANI) SIC KINLEY

to 48 houtirs' dutration wh-Iile those who ul-timcatelv died from perforation wvere ad-iitted even later.Somiie imiention of the length of time be-

tween admlnissioni to the hospital and opera-tion is appropriate. The length of time fromadmuissioni to the beginning of induction ofanesthesia wvas noted in each case. Com-parison of these times for the four periodsof study revealed little change. In Period I,69 per cent of the patieints were operateduipon wvitlhin two lhouirs of admission, 79 percent Nwithin six honlrs, and 84 per centw\ithin 12 houlrs. Comparative figures forthe last five years of this study, Period IN',were muarkedl similar, being 59 per cent,79 per cent, and 83 per cent.

Condition of Appendix

The condition of the appenidix at thetiIme of operation was noted in eaclh case.It wNas listed as being intact, perforatedwith abscess (or localized peritonitis), or

Nnnals of SurgeryJuly 195(

perforated wvith generalized peritonitis. Ifthere wvas disagreement between the op-erator s note anlle the patlhologists report,the latter wvas accepted. A fewr cases inwhich tlhere was apparent wound contam-ination at the operating table were incltndedin the intact grouip rather thannmollify theresults of the groups w\ith complicated ap-pendicitis.One problem w\vitlh the above grouping is

that the grossly intact appen(lix mniay be sostructurally altered by infl'ammation tlattransudation of bacteria through its wvallwith restulting peritoneal contaimination mayha-ove occtnrredl. If the peritoneal fluid is notctulttured stich a conditioni maiy be indle-tectecl. In any event the appendix wouldordinarily be consider-ed intact, w7hich isnot correct, lbacteriologicall7 speaking.

This error of classification was constantthrouighotut the period of study since, uin-fortunately, few cultures wvere taken. Cer-tainlv the more frequieint coinsideration of

ACUTE APPENDICITIS - PERFORATED CASES

DURATION OF SYMPTOMS PRIOR TO ADMISSION

NUMBEROF

CASES

40 -

30 -

20-

10 -N..K

PERIOD I PERIOD II

Ficunim 3.

PERIOD II1 PERIOD IV

ACUTE APPENDICITIS

culture at the operating table and the con-cept of the bacteriologically rather than thegrossly perforated appendix would be ofvalue.The proportion of appendices which were

either intact or perforated was pointedlystable. Thus the percentage of cases withintact appendices in each of the four suc-cessive periods was 77 per cent, 75 per cent,76 per cent, and 72 per cent (Fig. 5). Thisis not surprising when one recalls that therewas no apparent change in the elapsedtime from onset of symptoms to operationthroughout the period of study. Conffictingreports of changing incidences of perfora-tion have been published from other in-stitutions.

Antibacterial Agents

In our institution sulfonamide compoundswere first used in the treatment of acuteappendicitis in 1938. In that year five of 75cases (6.7 per cent) received either Ne-oprontisil or sulfonilamide. Only two ofthose cases were in the perforated groupdespite the fact that there were 21 patientswith perforated appendices treated thatyear. By 1940, 28 per cent of the patientswith perforated appendices received sul-fonamide therapy, by that time predom-inately sulfonilamide. One case received a

combination of sulfonilamide and sulfathi-azole. In the first five years of this study,Period I, 9.5 per cent of the patients con-

sidered received sulfonamide therapy (Fig.6). More than one-third of the patients so

treated were in the nonperforated group.Penicillin was first used in Period II, in

1944, when four cases received it in con-

junction with sulfonamide drugs. An addi-tional 26 cases received only sulfonamides.By the following year penicillin had be-come the principal antibacterial adjuvant.Thirty-six per cent of the cases treated inthat period received antibacterial agents.Again, more than one-third of the cases so

treated were in the nonperforated group.

ACUTE APPENDICITIS

DURATION OF SYMPTOMS PRIOR TO ADMISSION

CASES DYING OF INFECTION

NUMBEROF

CASES

9 *o A

,c

I

5-

3 SCA a

la N0

%0

+0

PERIODS I - IV

(1936-1955)

FIGuRE 4.

The intraperitoneal use of sulfonilamidepowder was in vogue during much of thisperiod. Its use was minimized after one pa-tient died from intestinal obstruction sec-

ondary to adhesions resulting from suchpractice, and abandoned following reportssuch as that of Meleney8 of its lack ofeffectiveness when used locally.

Period III was that of predominate pen-icillin and streptomycin therapy. The latterdrug was first used in 1947 and althoughused alone in a few cases its use in conjunc-tion with penicillin comprised the chiefantibacterial treatment during that time.During Period III only two patients re-

ceived broad spectrum antibiotics. In thatperiod, 58 per cent of all cases receivedantibacterial medication; more than one-half of those receiving it were in the non-

perforated group.In Period IV, penicillin with streptomycin

continued to be the basic antibiotic agents.

Volume 150Number 1 135

B3ABCOCK A\NI) SIC KINLEY .Aiiinls if SurgeryJuly 1959

ACUTE APPENDICITIS

CONDITION OF APPENDIX AT OPERATION

I - intactLP - perforated with localized peritonitisGP - perforated with generalized peritonitis

U]

0

H

z

v

80 -

75 -

70 -

15 -

10 -

5- ~IY

7

/

///

L4 L4

PERIOD I PERIOD II PERIOD III PERIOD IV

FIGURE 15.

Broad spectrum drugs ere used when cul-ture and sensitivity studies suggested theirgreater effectiveness or when the clinicalcourse indicated the need for additionalanutibiotic agents. In this period 61.5 per

cent of the patients received antibioticmedication; more than one-half of those so

treated wvere in the grossly intact group.

Attention lhas been called to the fact thata rather large proportion of the cases ineach period wNho received antibacterialtherapy wvere in the grossly nonperforatedgrouip. The reasons for this Ino doubt in-cluided the suspicionl thait there was per-

forationl wN-hiiclh w\vas grossly unIirecognized,

contiaimiinattion duriing operation, coincidentinfection in other tissues, or juist a desire toleave no therapetutic aid ulnutsed.A sumimary of the uisage of the various

antibacterial agents is given in Figure 6.

No stulfonamide compouinds w7ere tused inthe last two periods in study-. Intraperito-neal antibiotics were not used.

Morbidity

In order to obtain some measure of inor-

biditv each case which had a temperatureelevation greater than 100.60 F. (101.60rectally) for two consecutive davs w,vas clas-sified as morbid and the ntumber of days oftemperature elevation above that levelnoted. Needless to say, some patients who

'were clinically morbid or even some thatexpired did not necessarily have prolonged,or any, fever. Nevertlheless, it was believedthat stulch a classification provided consider-able insight into morbidity in coimplicatedappendicitis. There was a progressive de-cline in the number of morbid cases in each

five-year period as illustrated in Figure 7.

136

-

ACUTE APPENDICITIS

ACUTE APPENDICITIS

USE; OF ANTIBACTERIAL AGENTS IN SUCCESSIVE FIVE YEAR PERIODS

ANTIBACTERIAL AGENT

S - SulfonamidesP/S - Penicillin and/or

St reptomycinBS - Broad SpectrumT - Total

X Q

/n/0

/4

PERIOD IU PERIOD III

FIcURE 6.

PERIOD IV

In Period I, 33 per cent of all cases were

morbid; in Period IV only7 8.5 per cent wvere

so complicated. It should be recalled thatthere was no decrease in the relative num-

ber of perforated cases duiring successiveperiods.The number of morbidity days was also

tabulated and for comparison each vTear

w7as corrected to 100 cases. The morbiditydlays per 100 cases (five year averages) -was

compared (Fig. 8). There wvas a progressivedecline from 176 morbid days per 100 cases

in Period I to 29.4 days in Period IV. Onthis same figure is compared the nunmber ofmorbidity(days per 100 cases (fixve y-earaverages) in patients with intact and per-

forated appendices. The nuimber of mor-

biditv days associated wNitlh 100 intact ap-

pendlices was reduced in Period IV toapproximately ),l, that of Period I. In re-

gard to the perforated cases, less improve-

ment as noted for the number of mor-

biditv davs in Period IV was 14 that ofPeriod I.

Mortality

Thirty-five deaths were encountered inthis 20-year review, a gross incidence of2.1 per cent. Four cases were not operatedupon so that the mortality of operated cases

was 1.9 per cent. The incidence in five-yearperiods is shown in Figuire 7. The imortalityof all cases treated during the last five-yearperiod was 0.5 per cent. Excluding the one

unrecognize(l, tinooperated case, meentione(ll)elo\v- it wX7aS 0.25 per ceint.

Of the fouir uolRoperated cases, two were

admitted in extremiiis and (lied in 12 and 30lhouirs respectively. The otlher two wvere u-n-

diagnosed uintil autopsy. One of tlhese, thelast deatlh in this instituitioni duie to appen-

dicitis, .was adnmitted in Septemnber 1954

\duIl mllle 150NuLmber 1 137

PERCENTAGEOFCASES 70-

60 -

50-

40-

30

20-

5 -LO

PERIOD I

H

BABCOCK AND MC KINLEY Annals of SurgeryJuly 1959

ACUTE APPEND]

MORBIDITY AND

33 -

30 -

>'

0

04

20

10 -

5-

2-1-

mbmt

PERIOD I II

FIGURE 7.

and expired in April 1955. 143-year-old laborer with bulbtis, was in a respirator forProgressive abdominal pain,terioration during the last twwere considered to be due t(of previously diagnosed ripyelonephritis. Surgical connot requested. Necropsy re,

eralized peritonitis, the res

diceal perforation.Comparing the death rate

found that 19 of the 35younger than ten years or

years. Although these age groonly 19 per cent of the tolpatients, they contained 54 Edeaths. There were 848 patie

[CITIS ond and third decades, but only four deaths.

MORTALITY In these decades were 51 per cent of thepatients, but only 11 per cent of the deaths.The problems of diagnosis and treatment

Morbidity in the young or old have long been empha-Mortality sized but many times forgotten. Wolfe 12

found a serious delay or error in initiatingproper treatment in 25 per cent of patients65 years of age or older as compared with5.5 per cent in a control group, aged 30 to

40 years.

Comparing the number of male and fe-male deaths yielded the ratio of 1.9 to 1.This is in general agreement with the 1.45to 1 ratio found in the total number of cases.

The principal cause of each death was

ascertained and listed in Table II. In ninecases, infection did not play a significantrole. Fatal pulmonary embolism occurredfour times, an incidence of 0.24 per cent.There were two deaths in the last five-yearperiod, both the result of peritonitis.

Mortality was further considered withregard to the condition of the appendix.Review of the intact cases revealed that the

E total mortality for the 20-year term was 0.7

m IVper cent and that in 0.24 per cent deathoccurred as the result of peritonitis. The

fact that there were any deaths due tointra-abdominal infection must mean that

ahis patient, a there was peritoneal contamination during

seven months. operation or that there had been "bacterio-ileus, and de- logic perforation" of a grossly intact ap-o weeks of life pendix. In this, the intact group, there were

no deaths due to any cause in the last fiveo a recurrence

years of the study.

isultation was

vealed a gen-

ult of appen-

to age it was

patients were

older than 59ups comprisedtal number of:er cent of theInts in the sec-

TABLE 2. Mortality of Acute Appendicitis 1936-1955

Cause of death No. of Cases

Perforation, peritonitis 26(four cases not operated upon)

Pulmonary embolism 4Cardiac failure 2Uremia 2Intestinal obstruction 1

Total 35

138

I -E

ACUTE APPENDICITIS

ACUTE APPENDICITIS

LENGTH OF MORBIDITY IN SUCCESSIVE FIVE YEAR PERIODS

Condition of Appendix

I - IntactLP - Perforated with localized peritonitisGP - Perforated with generalized peritonitis

II ~ T - Total

I III

/

Ill IV

FIGURE 8.

The perforated cases were considered inregard to percentage mortality in each pe-

riod. Figure 9 shows that the mortality dueto peritonitis was 17 per cent in Period I,but had declined to 1.8 per cent in PeriodIV. The total mortality of all cases withperforated appendicitis for the 20-year pe-

riod was 6.5 per cent. For the first periodit was 19 per cent; for the last, 1.8 per cent.The apparent discrepancy between totalmortality and mortality due to perforationand peritonitis is accounted for by the factthat three patients in this group who were

combating well the effects of perforationdied from seemingly unrelated causes. Twoof these cases were in Period I; one was in

Period IL. Comparison of mortality in theearly periods of this study with other serieswould suggest that our results for that timewere good although we were operating on

all perforated cases then as now.

DiscussionCertain factors in treatment, yet unmen-

tioned, which are of major importance inpatients with peritonitis deserve comment.Intestinal intubation, blood, plasma andsubstitutes, and parenteral fluid and elec-trolyte replacement may, with judicious use,permit the survival of a critical case. All ofthese measures aside from plasma and sub-stitutes were in general use here throughout

Volume 150Number 1

1 80

150 -

139

100 -

u]

uoHu0

04

I-

0

wa4

0

1.

z

50 -

40 -

30 -

20 -

10 .04-1

P.ERIOD I

L-

BABCOCK AND MC KINLEY Annals of SurgeryJuly 1959

ACUTE APPENDICITIS - PERFORATED CASES

MORTALITY IN SUCCESSIVE FIVE YEAR PERIODS

Tmt - Total mortalityPmt - Mortality due to perforationOmt - Mortality due to perforation

(Operated Cases)

o 15

z

u

aWd

IF0:

0

3

FN A.O F X O

PERIOD I II

IE E0

II

E E ENI. 0

IV

FIGuRE 9.

the period in study although blood was

more available in the last ten years andfluid and electrolyte replacement was givenon a more rational basis.The value of early ambulation became

recognized during the term of study. It,together with anticoagulant agents, has an

important place in the avoidance of the direconsequences of thrombo-embolic disease.In this study only four cases of fatal pulmo-nary embolism occurred. Two of these cases

had intact appendices. None occurred inPeriod IV.

Generally, spinal anesthesia, usually sup-plemented with other agents, was used inthe cases presented here. No death was re-

lated to anesthesia. No known residuum ofthe anesthesia was encountered.The type of incision used has been con-

sidered important by many writers. Thus in1946 Meyer, Requarth and Kozoll 9 statedthat "the closer to the midline the incisionis made, the higher the mortality rate."Many surgeons have dogmatically adoptedthe McBurney incision. Slattery 10 et al.,and others (Abel and Allen,1 Bower andFreed 2), related decreasing mortality ofappendicitis to the increased use of that

incision. We cannot disagree by havingcompared the results of treatment usingvarious incisions, but since our results witha pararectus incision in a similar periodwere essentially the same as others whoused the McBurney type, we agree withHawk, Becker, and Lehman5 that thechoice of incision is not a major issue. Goodresults without inversion of the appendicealstump have led us, as they have others(Jordan and Hollenbeck 6), to believe thatsuch a practice is unnecessary.

No interval appendectomies were per-

formed during the period of study. Cer-tainly during the pre-antibiotic years some

of the cases with abscess had a stormy post-operative course which not rarely termi-nated fatally. It would seem that such cases

need not be rushed to operation. Timeshould be taken to resolve adequately aber-rations in electrolyte balance and bloodvolume. The presence of significant levelsof antibiotics in body tissues at the time ofoperation would theoretically aid in min-imizing dissemination of the infection. Thevalue of a gentle approach to and skillfulevacuation of an appendiceal abscess can-

not be over-emphasized. Important pointsnoted by Boyce 3 are not to mistake forabscess a phlegmon surrounding an unrup-

tured appendix and continued expectanttreatment until perforation has occurred,and to realize that an apparently stableabscess may rupture.

Summary and Conclusions

1. All cases of proven acute appendicitistreated at the Geisinger Memorial Hospitaland Foss Clinic from 1936 to 1955 were

critically analyzed. The 1,662 cases were

grouped in five-year periods.2. The uniform concept of treatment in

which all patients were operated upon ir-respective of possible perforation, a conceptnot commonly practiced twenty years ago,

added to the stability of the study and thusfacilitated the evaluation of other factors.

140

I

Volume 150 ACUTE APPENDICITIS 14Number 1

3. The uniformity of the clinical pictureleading to diagnosis and operation was re-markable. No significant change was notedin respect to age, sex, duration of symp-toms, and condition of appendix when thecases were compared in successive five-yearperiods.

4. The use of the various antibacterialagents was reviewed. During Period IV(1951-55) 61.5 per cent of the patients re-ceived such treatment. More than one-halfof those cases had grossly intact appendices.Penicillin and streptomycin remained thebasic antibiotics used; broad spectrumagents were added when indicated.

5. Morbidity and mortality were con-sidered in successive periods in regard tototal incidence and relative to duration ofsymptoms prior to operation and to thecondition of the appendix. 33 per cent ofcases were morbid in Period I; 8.5 per centin Period IV despite the fact that there wasno decrease in the incidence of perforation.The gross mortality for the 20-year periodwas 2.1 per cent; that of operated cases was1.9 per cent. During the first five years con-sidered, Period I, the mortality of operatedcases was 5.5 per cent; in Period IV it was0.25 per cent. Of the total number of 35deaths, 26 were due to peritonitis and itssequelae.

6. Type of incision and stump manage-ment were considered unimportant. Resultshere were not inferior to those reported inseries in which other technics were used.

7. The refinement and appropriate use ofadjuncts such as intestinal intubation, bloodand fluid replacement and improvements inanesthesia are noteworthy but the markedimprovement in results of treatment ofacute appendicitis found in this study ap-pears to parallel the use of the antibacterialagents.

8. It would seem incontrovertible thatthe use of antibiotics-penicillin, streptomy-cin, and the broad spectrum agents-during

the last decade of study was of major im-portance and the principal cause for themarked reduction of morbidity and thenear elimination of mortality of appendici-tis. It should be emphasized that the anti-biotics remain as adjuvants in treatment,their effectiveness being predicated by theremoval of the offending organ and thedrainage of any reservoirs of infection.

Bibliography1. Abel, WV. G. and P. D. Allen: Acute Appendici-

tis in Children. Ann. Surg., 132:1093, 1950.2. Bower, J. 0. and C. F. Freed: Report of the

Third State-wide Survey of Acute Appen-dicitis Mortality (1946). Pennsylvania Med.J., 51:58, 1947.

3. Boyce, F. F.: The Role of Atypical Disease inthe Continuing Mortality of Acute Appen-dicitis. Ann. Int. Med., 40:669, 1954.

4. Cantrell, J. R. and E. S. Stafford: The Dimin-ishing Mortality from Appendicitis. Ann.Surg., 141:749, 1955.

5. Hawk, J. C., W. F. Becker and E. P. Lehman:Acute Appendicitis III. Ann. Surg., 132:729,1950.

6. Jordan, G. L. and G. A. Hollenbeck: CurrentTrends in Emergency Surgical Treatment ofAppendicitis. Proc. Staff Meet. Mayo Clin.,28:5, 1953.

7. McIver, M. A.: Acute Appendicitis in a RuralCommunity, Series III. Ann. Surg., 145:522,1957.

8. Meleney, F. S.: A Statistical Analysis of aStudy of the Prevention of Infection in SoftPart Wounds, Compound Fractures, andBurns with Special Reference to the Sul-fonamides. Surg., Gynec. & Obst., 80:263,1945.

9. Meyer, K. A., W. H. Requarth and D. D.Kozoll: Progress in the Treatment of AcuteAppendicitis. Am. J. Surg., 72:830, 1946.

10. Slattery, L. R., S. A. Yannitelli and J. W.Hinton: Acute Appendicitis. Arch. Surg., 60:31, 1950.

11. Snyder, W. H. and L. Chaffin: AppendicitisDuring First Two Years of Life. Arch. Surg.,64:549, 1952.

12. Wolfe, W. I. and R. Hindman: Acute Appen-dicitis in the Aged. Surg., Gynec. & Obst.,94:239, 1952.