According to Lewin, the local applica tion of heat will show whether an in flammatory process has progressed to suppuration or not. In appendicitis, if pus has not formed, the application of heat will be a comfort to the patient.
If pus is present, the pain will increase in severity. Eight of 10 cases in which heat was applied for two hours by hot compresses experienced marked relief, while in the other 2 there was increase of pain. These 2 died from extension of the suppuration. Spoilr has had a similar experience in 15 cases. Editorial (Therap. Gaz., May 15, 1901).
If suppuration is present and perfora tion occurs on the fourth or fifth day, i.e., after the adhesions have formed, —the symptoms do not, as a rule, vary from those enumerated. When, how ever, they do not assume a graver form during the first four days, the presence of protective adhesions is likely.
Danger may exist without being shown by pulse or temperature. Pulse, tem perature, and pain may decline, marking the occurrence of effusion: a deceptive calm. The sudden access of intense local ized pain indicates a dangerous change in the local conditions. G. F. Shrady (N. Y. Med. Record, Jan. 6, '94).
A pulse-rate of 120 indicates a con siderable infection, and, according to some, is an absolute indication for opera tion. Richardson (Amer. Jour. Med. Sciences, Jan., '94).
Too much stress must not be laid on the temperature, as recovery may follow a temperature of 105° F. and death may occur with one nearly normal. Richard son (Amer. Jour. Med. Sciences, Jan., '94).
When the symptoms are marked and a tumor cannot be felt, perforation has probably occurred before the adhesions were sufficiently perfect to protect the peritoneal cavity.
If perforation has occurred early, i.e., while the adhesions were still im perfect, there is usually a chill and vomiting; shock, more or less profound; diffuse, marked pain, instead of the lo calized pain; acceleration of the pulse; an iucrease of temperature of 2° or 3° F.; scanty and dark urine, showing high specific gravity.
The cause of diffuse peritonitis com plicating appendicitis, ascertained by personal clinical observations, is as fol lows: 1. Peristaltic motion of the small
intestines is the chief means of carrying the infection from the perforated or gangrenous appendix to the other por tions of the peritoneum, changing a cir cumscribed into a general peritonitis.
2. This can be prevented by prohibiting the use of every kind of food and cathartics by mouth, and by employing gastric lavage in every case in which there are remnants of food in the stom ach or in the intestines above the ileo cfccal valve, as indicated by the pres ence of nausea, vomiting, or meteorism.
3. The patient can be supported by the use of concentrated predigested food ad ministered as enemata not oftener than once in four hours, and not in larger quantities than 4 ounces at a time. 4. This form of treatment, when instituted early, will change the most violent and dangerous form of acute perforative or gangrenous appendicitis into a compara tively mild and harmless form. A. J. Ochsner (Amer. Surg. and Gymec., Jan., 1902).
Perforation is also accompanied by distension of the abdomen, and symp toms of grave diffuse peritonitis appear, followed by collapse. Dullness affords an early clue to the presence of pus.
Distension of the abdomen depends, for its importance, upon its cause. Opium may cause it or gas may form. If peri stalsis is not inhibited no alarm need be felt. Distension due to local infection is of the gravest import. Richardson (Amer. Jour. Med. Sciences, Jan., '94).
Increase of both pulse and temperature from a condition showing a slightly ac celerated pulse and a temperature of 100° to 101° F., combined with increase of the other symptoms, indicate a danger ous condition. G. F. Shrady I'. Med. Record, Jan. 6, '94).
General abdominal distension is the most dangerous symptom. Gage (Boston Med. and Surg. May 24, '94).
A point of marked dullness in eases without any pronounced inflammatory symptoms was always found when the appendix was indurated and adherent to the adjacent tissue. In all of 19 cases in which dullness was present pus was diagnosed. This was verified either by operation or by autopsy, except in 2 cases. H. T. Miller (Med. Record, Feb. 9, 1901).