6. Vomiting is absent in the milder cases of appendicitis, yet it is often an early and ominous sign. In the milder forms of periappendicitis, vomiting is absent and severe gaseous eructations are almost always absent, except when they are the beginning of further progressive symp toms. At any rate the greater the participation of the abdomen in the disease, the more permanent is the vomiting; in severe eases, often after every bit of nourishment. Remission of vomiting. or its recurrence, is, as with the bowel movements, useful in the prognosis of the course of the disease. The vomiting of dirty coffee-brown masses, stained with hfematin clots is ominous (paralytic liens).
(b) GENERAL SYMPTOMS The general symptoms are especially important for the individual judgment of the severity of the disease and for therapeutic measures. It is not safe to draw conclusions from merely one of the general symp toms alone. Therefore the whole combination of the general symptoms, in connection with the local symptoms, is alone authorative. For instance, a rise of temperature, or an increase of the pulse rate, which often occurs, does. not justify the conclusion that there is an exten sion of the perityphlitic inflammations. since the increase of tempera ture can also result from a diminution of the shock occasioned by perforation of the appendix. Concerning this last aspect of the case, the previous general symptoms, especially the blood examination and the local symptoms, give us a clue. Moreover, it is not always \Via' to give heed to separate symptoms, especially when taken singly.
1. The mental condition is dependent upon the severity of the infec tion and the cerebral amernia which results from the congestion in the abdominal vessels, and is to be judged by the COUPS(' of the remaining general symptoms.
2. The increase in body temperature is always variable in ap pendicitis, as well as ip periappendicitis, and shows nothing character istic. Appendicitis and periappendieitis are accompanied with low or with high temperature, which is of slight importance except that some conclusion as to the severity of the disease from this symptom can be gleaned, especially as regards a perforation. The temperature is de pendent in many cases upon the shock and severity of the infection.
3. The behavior of the heart shows the same significance, and the quality and frequency of the pulse has significance only in conjunction with other symptoms. Small, slow or accelerated pulse in attacks of
spasmodic appendicitis, or in threatened perforation, are in children ofte» observed as the result of shock, not alone as evidence of sepsis. Smaller, more frequent or slower pulse, cyanosis, and coldness of the extremities, are not only the evidences of a more severe infec tio», hut often show only the amount of congestion in the abdominal vessels.
4. Concerning the symptoms on the part of the blood, and especially the leucocyte count, significant observations have been made following Curschmann. In general, there is a rise of the leucocyte count to Oventy or thirty thousand, per millimetre in perityphlitic suppuration. Re duction or great increase of the leucocyte eount is found in acute cases of peritonitis, running a foudroyant course and usually terminating in death.
With otherwise severe symptoms, a low leucocyte count is of ominous meaning. A rise in the leucocyte count gives hope of improve ment. In the further progress of the disease, a reduction or increase of leucocyte's (leucocyte curve) in eonjunction with the pulse and tem perature, is of value in general prognosis, and also in particular regard to the surgival aspect of the case: a falling of the leucocyte count, t gether with a coincident lowering, of the pulse anff temperature to normal, shows a favorable progress. . \ rise of all these curves means relapse of the inflammation: and crossing by the leucocyte curve of the rising pulse C1.11.V is unfavorable in prognosis. For differential diagnosis from ileus, as well as for confirmation of a suspected sup purative perityphlitis, the leucocyte curve is of service. For this, how ever, a more thorough investigation is necessary, which is difficult for the general practitioner. For the severer eases, with undoubted impli cation of the abdominal wall, and threatening general perityphlitis, the leucocyte count should be subordinated because of the urgent symptoms, to the general findings otherwise observed.
Diagnosis.—The diagnosis of the disease, after the preceding, should be elear. The trouble lies in the differentiation of appendicitis from periappendicitis, and the diagnosis of the various forms of the latter, for which our treatment is different.