The actinomycotic form is character ized by slower progress and less acute symptoms.
In the rheumatic form there is much tenderness over the appendix. No tumor or dullness can be detected. Arthritis, however, is present.
Case of rheumatic perityphlitis show ing much tenderness in the right iliac fossa, but no tumor or dullness; with arthritis. The diagnosis proved by the fact that the salicylates rapidly pro duced a beneficial effect. I. Burney Yeo (Brit. Med. Jour., June 16, '94).
The infectious form is distinguished by a rapid course.
The disorder called by Poneet "acute infectious appendicitis" is distinguished by its rapid involvement of the perito neum, without ulceration, perforation, or gangrene. It results from occlusion of the orifice of the appendix by inflam mation, and absorption of its contents; the presence of the bacillus coli corn munis is thought also to have an im portant influence. Clinically, it does not differ from other forms of the disease except in its rapid course. Margery (Jour. de Me'd. et de Chir. Pratique, Feb. 25, '93).
When appendicitis occurs during preg nancy, the attack is usually sudden and begins with abdominal pain which grad ually becomes localized; this is followed by the typical symptoms. This condition must be carefully differentiated from tubal pregnancy. The prognosis is grave.
Appendicitis complicating pregnancy is difficult of recognition and the cause of great mortality. Ilrawacek cites 13 eases of catarrhal appendicitis with preg nancy, 5 cured without operation, operations, and 7 deaths. Case in which' abscess associated with a necrosed ap pendix was removed without disturbing the pregnancy; three months afterward the patient gave birth to a healthy child, having a normal delivery and puerpe rium. Appendicitis sometimes appears as a complication of diseases of ovaries and appendages. Martin in 171 oper ations for right-sided salpingitis and 276 double•sided found appendicitis 6 times in connection therewith; Diihrssen in one and one-half years, out of 322 lapa rotomies, had 10 cases of diseased ap pendix; Ochsner, of Chicago, in 51 oper ations for primary appendix found 15 times secondary disease of the append ages. Otto Falk (Centralb. 1. Gynlik.,
Feb. 17, 1900).
Diagnosis, General. — During exami nation gentle manipulation is necessary, lest an abscess be present and the sions be delicate and unable to stand the traction or pressure. (McBurney.
The amount of manipulation necessary to make a complete diagnosis should be of the very lightest possible kind. Any thing more than very light manipulation in one of these cases must be accom panied by a certain amount of danger, because we do not know the thickness of the barrier between abscess-cavity and the peritoneum. MeBurney (Buffalo Med. Jour., June, '96).
The location, direction, and extent of the appendix have an important bearing on the clinical history of appendicitis, considering the variations of the appen dix in length, direction, and location, and the varying site of the ctecum.
It is quite possible to feel the normal appendix in most cases. If one palpates gently with two or three fingers on the opposite side one can readily get the landmarks. The ascending colon is the first landmark. Three fingers are placed upon the rectus muscle, then brought down over the edge of the muscle, three fingers of the right hand being used to feel with and the three fingers of the left hand to press with. The examining fingers are pressed by means of the three others down under the border of the right rectus abdominis muscle at the level of the navel, and slowly drawn to the examiner. The landmark, the as cending colon, is then felt to slip out from under the fingers, and, by repeating the process toward the etecum, one soon comes to the end of the latter, and there begins to limit for the appendix by roll ing the c[ecum to one side or the other of the finger-tips. The proximal end of the appendix is found near the distal end of the ewcum; the remainder of the appendix is followed in any direction. The proportion of appendices that cannot be palpated will become smaller as the finger-tips become educated. The very delicate sense of touch is preserved if the left hand is used for pushing upon the examining hand. Robert T. Morris (In ternational Jour, of Surg., Aug., '98).