The important feature is to differen tiate between the catarrhal and non penetrating forms, and the septic and gangrenous forms, of appendicitis. The following general rules suggested: A temperature in the beginning of 102°, or a temperature above 100° continuing until the second day, indicates operation. A rapid, feeble pulse, without rise of temperature, suggests a gangrenous or septic process. Leucocytosis of more than 20,000 indicates operation. A. L. Benedict (Med. News, Dec. 1, 1900).
In the diagnosis of suppurative ap pendicitis the white blood-count is of the greatest importance. A sudden hyperleucocytosis points to a complica tion in an infectious fever,—typhoid, for instance,—and if sudden abdominal pain appear an exploratory incision is warranted, as is the practice in the Johns Hopkins Hospital. Hyperleuco cytosis at once differentiates a sup purative appendicitis from simple co litis, typhoid fever, ovarian neuralgia, impaction of and floating kidney. By a blood-count pus can be detected within twenty-four hours, and an un favorable prognosis converted into a very favorable one. Robbin (Med. Record, Oct. 27, 1900).
Variations from the above course are occasionally met with. The disease may come on insidiously and fever or pain be totally absent. Although such an onset is occasionally met with in adults, it is most likely to occur in children. Occa sional colicky pains are sometimes the only early signs furnished, these being followed by the typical symptoms de scribed above. Slight appendicular le sions may be accompanied by alarming symptoms in hysterical patients, or in those mentally and physically below par.
Spurious symptoms often cause hesi tation. Case in which there were five attacks with symptoms of pericmcal ab scess and intestinal adhesions. Soft and rather large appendix the only condi tions present. In a second case, in which the only symptom was a painful spot, at least half a pint of pus found. Routier (Le Bull. Med., Jan. 30, '95).
The symptoms in a case of mild catar rhal appendicitis cannot at present, with certainty, be distinguished from those marking onset of case of the gravest type. J. W. (Brit. Med. Jour., Feb. 9, '96).
When examining a patient great at tention should be paid to the unequal susceptibility shown by various indi viduals; some react but little, while others, on the other hand, show reflex symptoms of great intensity. Two cases
showing that very slight appendicular lesions in hysterical patients may be ac companied by extremely alarming symp toms. Rendu (La Med. Mod., Mar. 24, '97).
The majority of errors in the diagno sis of intra-abdominal inflammations consist in mistaking atypical forms for other morbid conditions. List of 11 cases in which the mistake of regarding as appendicitis conditions which, upon operation or necropsy, proved to be other and unsuspected pathological processes. In 2 renal calculus, in 4 dis eases of the uterine appendages, in 1 sarcoma of the ileum, in 1 cholecystitis, in 1 acute suppurative pancreatitis, and in 2 to general sepsis. Brewer (Annals of Surg., May, 1901).
Progress toward simple perforation or perforation into a cavity bound by ad hesions is probable, when on the third day after the onset of the symptoms there is localized superficial oedema, indicating deep suppuration, and when a doughy mass is felt at the seat of pain, which mass gradually assumes shape to the touch, unless distended intestinal coils, shown by local tympanites, or the ten sion of the abdominal walls makes its detection impossible.
In three hundred cases the tumor in the right iliac fossa rarely showed itself before the third day of pain and tender ness. A tumor may, however, be due to accumulation of faces in the menu). Dullness on percussion is rarely recog nized before the fourth day. G. F. Shrady (N. Y. Med. Record, Jan. 6, '04).
Fluctuation does not generally occur until the second week. (Edema of the overlying integument does not occur until a paratyphlitic abscess has formed. G. F. Shrady (N. Y. Med. Record, Jan. 6, '94).
Diagnosis is made almost certain by the presence of a bunch, usually situated in the right lower quadrant of the ab domen or near the liver or left side. It may be obscured by abdominal disten sion or muscular rigidity. Gay (Boston Med. and Surg. Jour., Jan. 3, '95).
The presence of slight oedema over the loin is an indication of the presence of deep-seated suppuration. Symonds (Brit. Med. Jour., Jan. 26, '95).