Appendicitis

Acute Appendicitia.—There are three symp toms of acute appendicitis so constant and, when associated, so characteristic of the disease that they are designated the °three cardinal symp toms.' These are pain, tenderness, and rigidity of the right lower quadrant of the abdominal wall. Pain is the initial symptom, and usually develops suddenly in an individual previously well. At the onset of the affection the pain is paroxysmal or colicky in character, coming in storms with intervals of rest, in winch respect it simulates an attack of acute indigestion. The location is at first centred about the um bilicus, or the pit of the stomach, later it be comes diffused all over the abdomen, and finally localizes in the right iliac fossa. In recurr ing cases the initial pain of the later at tacks is often referred immediately to the right iliac fossa. The pain of appendicitis may, how ever, be referred to any region of the abdomen. It is ignorance of this fact that leads to many errors of diagnosis in acute abdominal affections. The location of the pain de pends to a great extent upon the position and direction of the appendix. For instance, with an appendix lying behind the cecum and point ing upward until its tip nearly reaches the gall-bladder, symptoms are produced resembling very closely those induced by affections of the latter organ. In other cases pain is felt in the left side of the abdomen and denotes that the appendix occupies a left-sided position or that it hangs into the pelvis. Tenderness upon pressure is one of the most valuable and constant signs of appendicitis. It is always present, but, unlike the subjective symptom, pain, it is limited at first to the site and the position of the appendix. To elicit this symptom abdominal pressure should be made in as light and delicate a manner as possible. The open hand should be laid over the tender area and the fingers gently depressed, ceasing as soon as the patient complains of pain. It should be remembered that the appendix may be distended with pus and on the verge of rupture, and any undue roughness in palpation may endanger the life of the patient. A celebrated German surgeon has truly said that °many a doctor whey has sufficient practice and experience nevertheless never learns to palpate, since he is wanting in lightness of hand.' It is a good plan to begin to palpate over on the left side away from the seat of pain, and gradually approach that region. As complications arise the point of tenderness may vary; for instance, in those cases previously re ferred to where the appendix occupies a pelvic position, the point of greatest tenderness will usually be found to the left of the median line. With the appendix thus located, where the dis ease has advanced to a stage where an abscess has formed in the pelvis, vaginal or rectal examination will reveal a point of resistance on the right side with more or less marked tender ness. The third cardinal symptom is rigidity.of the right side of the abdomen and particularly of the rectus and other abdominal muscles. It is the most constant symptom of the three and ap pears shortly after the onset of the attack. It varies in degree in different cases, but is gen erally well marked, and is most intense over the site of, the inflamed appendix. The variations observed range from rigidity so slight as to be barely appreciable up to a condition absolutely precluding any palpation, and to which the term uboard-like" rigidity is applied. The degree of rigidity is usually, but not invariably, in direct proportion to the severity of the lesion. When the peritoneal cavity becomes involved and peritonitis develops the entire abdomen becomes rigid and board-like, followed by dis tension or tympany from paralysis of the intestines. While the three cardinal symptoms are the most important indications of acute appendicitis, there are other clinical manifesta tions that are more or less constantly present and are of value in arriving at a diagnosis. Among these are disturbances of the gastroin testinal tract (nausea and vomiting, etc), ele vation of the temperature, increased pulse and respiration, changes in the urine, etc. Nausea is practically a constant symptom in appendicitis and usually coincides with the initial pain; it may be followed by vomiting, which at first consists of the gastric contents, then of bile or bile-stained fluid, and finally, if septic peritonitis develops, of the contents of the intestines. This condition, unless seen early, has frequently been mistaken by the family physician for intestinal obstruction.

In cases of appendicitis which progress rather rapidly to peritonitis, with the marked nausea and vomiting characteristic of the con dition, the pain suffered is apt to be very severe.

The attending physician, often following the promptings of the patient, administers the too convenient hypodermic of morphine, which while relieving the patient, at the same time masks the symptoms and renders the task of the sur geon, called in for consultation, an exceedingly difficult one. The giving of morphine for the relief of pain in appendicitis is a pernicious habit. Nausea and vomiting rarely persist after the pain has become localized to the right iliac fossa, though in some unfavorable cases vomit ing may be continuous and uncontrollable. The condition of the bowels previous to the attack of is very variable. In the ma jority of cases constipation is observed, and such sluggishness may represent an etiologic factor of some importance. But there are many cases where diarrhoea ushers in the at tack, and other instances when it may alter nate with constipation. Fever must not be re lied upon as a diagnostic sign, as it bears no direct relation to the gravity of the anatomical lesions. While with the onset of the disease the temperature usually rises to and F., it may return to normal again despite the advance of severe complications such as per foration or gangrene of the appendix. Coin cident with the development of an abscess around the appendix there is usually a rise of temperature, but again such a rise is not constant. There are, finally, some cases in which the temperature continues high from the commencement to the termination of the attack, and yet the patient makes an easy recovery. The amount of fever should there fore be considered as the expression of the reaction and resistance of the individual to infection. The condition of the pulse is a more constant diagnostic aid than the tempera ture and its quality is of more importance than its rate of speed. If the pulse is strong, of good volume, regular, and the rate proportionate to the temperature, the out look is favorable, and vice-versa. Variations in the respiration are not of much import ance. The breathing is embarrassed in toxic states, from the distension of peritonitis, and sometimes, owing to the pain, the patient will use the chest muscles entirely. A quite char acteristic position often assumed by the patient, and from which he resents being disturbed, is with the right leg and thigh flexed, while the left leg remains prone. In addition there may be perspiration, a furred tongue and a slight expression of anxiety upon the features. When the appendix occupies the pelvic position the patient will frequently complain of rectal and vesical (bladder) irritability. An increased fre quency in urination is the usual symptom, yet there may be inability to void urine. The symp toms which have been described are typical of the usual attack of acute appendicitis, though marked variations may occur, depending upon the position of the appendix or the presence of adhesions from former attacks. With a his tory of previous more or less severe attacks of abdominal colic, not necessarily referred to the appendix, a person previously well is sud denly seized with severe pain, usually through out the abdomen followed by nausea and sometimes vomiting, pain soon becoming more intense over the site of the appendix, and in a few hours this locality alone is involved; if such a patient should be so fortunate as to see his physician at this time, namely, within 24 hours of the attack, and if operation is ad vised and performed, recovery is practically as sured; but unfortunately this is not always the course pursued. The disease at this time is in

its earliest stage, with the inflammatory lesion confined to the appendix, and the particular sequence of events which may follow in a given case cannot be foretold. In some cases the appendix under the influence of rest is able to eliminate the noxious materials causing the inflammatory lesions, recover its vitality, and apparently return to as good condition as be fore the attack: but lymphoid (glandular) tis sue which has once been the seat of infection is exceedingly prone to future attacks. In still other cases the disease extends through the wall of the appendix and induces a mild perito nitis localized in the coils of intestines and tis sues immediately contiguous to the appendix. With the appearance of infecting bacteria or of their poisons in the peritoneal cavity, this mem brane throws out a thin fluid or serum and an exudate (lymph) which organizes into firm tis sue, knoivn as adhesions. These adhesions glue the coils of intestine surrounding the ap pendix together, causing them to adhere to the roof of the cavity, which is the ab dominal wall, and with the aid of the omen tum, a fatty apron-shaped body covering the intestines, form a firm wall about a cavity con taining the appendix and thus prevent the escape of toxic materials into the general peri toneal cavity. Should the disease, under medical treatment, subside, the lymphatics and the white blood corpuscles speedily destroy the in fectious material, but the adhesions too often remain and cause constant irritation. In time a period of chronicity is reached when any un usual exertion provokes a dull ache in the lower right quadrant of the abdomen. The digestion is impaired, and the bowels become sluggish in their movements from the dragging of the ad hesions upon the valve between the large and small intestines. In women subject to chronic appendicitis with involvement of the ovary and fallopian tube on the right side, slight attacks of appendiceal colic will recur during each menstrual period, and all treatment directed against dysmenorrhoea will prove un availing. The appendix in such cases may be come obliterated into a mere fibrous cord, or, more commonly, occlusion takes place at the opening into .the cccum or at the site of a stricture, and the appendix becomes distended with clear mucus. While operations upon chronic forms of appendicitis in the presence of adhesions are attended with but little risk, the operation itself is more tedious and the incision longer than when the disease is operated on in its early stages. Having dealt with the favorable terminations of acute appendicitis, it remains to consider that far too numerous class of cases in which the appendix per forates, with abscess formation and some times general peritonitis. If the infection of the appendix is severe enough, its walls may become gangrenous and break down and per forate into the peritoneal cavity. In this case the peritoneum usually becomes in fected in advance of the perforation and enough time is gained for the formation of ad hesions such as have been described. In what is known as fulminating appendicitis the prog ress of the disease is so rapid that no ad hesions are formed, and in 24 hours, or less, after the onset of the initial symptoms the patient may be suffering from a.violent general peritonitis. But, as a rule, 'the escape of purulent material through a perforation in the appendix occurs into a preformed cavity, the walls of which consist of the abdominal wall the iliac fossa, the cecum and matted coils of small bowel and the infiltrated omentum. This cavity becomes filled with pus and a true ap pendiceal or peri-typhlitic abscess is formed. The amount of pus varies from a teaspoonful to a pint, or in extreme cases even more. With the formation of the abscess the symptoms change somewhat. The severe pain of the early inflammatory stage becomes more dull; sometimes is referred to the back or to the left side, tenderness is increased, while the rigidity is more marked. The tongue becomes coated and the breath foul, chills are rarely observed even in the presence of pus, and when present — especially a single, severe chill ushering in an attack — usually mean a gangrenous condi tion of the appendix. There is fever, increased pulse-rate, and the patient shows the effect of absorption of poisonous products into his gen eral circulation. An examination of the blood shows an increased number of the white blood corpuscles (leucoeytosis). Palpation of the abdomen will reveal a mass in the right iliac fossa, rounded, hard and often tender. The patient may not complain of any pain beyond the dull ache referred to, though the act of coughing•or taking a deep breath usually re sults in an exacerbation of pain. In some cases with an appendix deep in the abdomen and behind the cecum, an abscess may exist which cannot be palpated. When such a condi tion is suspected it is not wise to prod the ab domen too hard for fear of rupturing the ab scess. If the pus extends into the pelvis the additional symptoms of vesical and rectal ir ritability will be present and vaginal or rectal examination will detect a bulging area ex tremely tender to the examining finger. In women and girls the effect of such a pelvic ab scess is frequently disastrous. The open ends of the fallopian tubes become bathed with the Pus, and either a salpingitis or occlusion of the tubes takes place. The tubes are thereby pre vented from fulfilling their function of trans mitting the ova to the uterus, and sterility may result. The extension of the pus upward toward the liver causes symptoms very much resembling infectious gall-bladder disease; this will be discussed under differential diagnosis. In neglected cases this upward extension of pus has resulted in the formation of an abscess beneath the liver, with rupture through or ba hind the diaphragm, and entrance of the pus into the lung and pleural cavity from which it has been actually evacuated by coughing and expectoration. If an appendiceal abscess is small, recovery may occur without operation, although such a happy result is doubtful. The disease is progressive, and the pus tends to in crease, and if not evacuated will frequently rupture the walls of the containing cavity into the cecum. occasionally, but more often, unfor tunately, into the peritoneal cavity, with a re sulting general purulent peritonitis and almost invariably a fatal outcome. In such a case the pulse increases in frequency and becomes full and strong, the face becomes pinched and anxious, the eyes brighten, the mind becomes active, though delirium appears later, the abdo men slowly distends, accompanied by marked pain and restlessness of the patient. These three pathognomonic conditions, a bright eye, an active mind and a swollen belly, indicate approaching dissolution. The distension is due to a paralysis of the bowels, gas and feces be ing retained in spite of all treatment. Nausea and vomiting soon begin, the latter at first green, but later black, from evacuation of the contents of the intestines into the stomach. Death rapidly follows.