The diagnosis of appendicitis from other lesions of the abdominal cavity, if seen early, is comparatively easy in the great majority of cases. Particular attention should be paid to the history of the patient, and espe cially to the character of the onset of the illness and the earlier symptoms. While inflammation of the stomach and intestines (gastro-enteritis) has caused some confusion at times, yet, un fortunately, the mistake is made more often in the wrong direction. That is, a true attack of appendicitis is thought to be gastro-enteritis and treated accordingly until the appearance of an abscess with its unmistakable symptoms warns the attending physician of the true nature of the malady with which he is dealing. While the pain in both diseases may begin over the stomach (in the epigastric region) and con tinue over the whole abdomen, in appendicitis the region of the appendix will be tender to palpation from the onset, and this tenderness will persist and even become more acute after the general abdominal pain has ceased. Uni lateral rigidity is quite constant in the beginning of the appendiceal attack, while in the gastro intestinal disease the entire abdomen may be rigid. In certain cases of gastric ulcer, with perforation and escape of the stomach contents into the peritoneal cavity, the shock is more marked from the onset, and the more severe symptoms will occur in the upper abdomen. Ulcer of the stomach is much more common in women than in men, and often gives symptoms which can be recognized long before the ulcer has advanced to the stage of perforation. In enteritis, or inflamma tion of the bowels, and particularly when poisonous food products have been eaten, the symptoms produce early and often marked shock. In the summer months iced drinks are a frequent cause of this complaint. About 18 hours after the dietary indiscretion there will be marked general abdominal pain, diarrhoea, chilliness, perspiration and a feeling of great weakness. In severe cases the depression may be so pronounced as to cause death (acute ptomaine poisoning). The greatest area of tenderness will be found about the centre of the abdomen, and careful palpation of the ap pendix region may find this organ neither en larged nor tender.
Mention was made earlier in this article of the symptoms produced by inflammation of an appendix behind the cecum and pointing up ward toward the gall-bladder. In such in stances the symptoms resemble very closely those due to inflammation of the gall-blad der and sometimes the two diseases cannot be differentiated with certainty. But as both affections require surgical intervention to effect a permanent cure, and as the incision in both instances is made in nearly the same place, the failure to make a correct diagnosis is not de trimental to the patient. The pain in the gall bladder affection, if referred, will cause a dull pain in the region of the liver radiating upward to the right shoulder blade. Tenderness is limited to the gall-bladder region and is a very important symptom, provided the rigidity of the right rectus muscle does not prevent palpa tion. The appearance of jaundice, or the char acteristic gallstone colics should decide the diagnosis. Later in the progress of the disease, the infection of the gall-bladder may produce pus, or empyema, as it is called, and the gall bladder can then be palpated as a round, tender and firm mass beneath the edge of the ribs and moving with respirations. An appendiceal ab scess would rarely reach as high as the costal margin without implication of the right iliac fossa, but in a high position it might be mis taken for a ruptured gall-bladder following empyema. In such a case the diagnosis would be almost impossible and practically immaterial, since the condition makes an operation impera tive. Neither an infected gall-bladder nor an appendix should ever be allowed to ad vance to the purulent stage without an opera tion being advised. Inflammation of the fallo pian tubes has been mistaken for appendicitis and vice-versa, particularly when the tube leak ing into the pelvic peritoneum causes a localized inflammation of that membrane. With the knowledge that the appendix frequently oc cupies the pelvis and may lie adjacent to the tube, the exact diagnosis of acute appendicitis from acute salpingitis may be difficult, and in chronic cases even more so. From the close proximity in which the two organs may be found the tube may be infected from the appendix or the latter may become involved secondarily from a pyosalpinx (pus in the tube). This still further complicates the dif ferential diagnosis. If a history of specific in fection can be obtained, with symptoms indi cating the commencement of the disease in the lower part of the abdomen, and a vaginal ex amination shows induration of the vault with tenderness to pressure on either side of the uterus, a diagnosis of salpingitis would be reasonable. A number of other diseases
may be suspected in deciding upon a diagnosis. Among these may be mentioned extra-uterine pregnancy, ovarian cysts, some kidney affec tions, intestinal obstruction, typhoid fever, pancreatitis, etc. The nature of this article does not warrant the full discussion of these affections.
The treatment of appendicitis has been a mooted question for some time, and it has only been within the last few years that the medical profession has accepted the dictum of those whose experience with the disease has been the greatest, that appendicitis is a surgical disease. The soundness of this teaching rests upon the fact that it is impossible to foretell in any individual case what the outcome will be, and which case will terminate favorably, or which will progress to perforation or gangrene, and the attendant peritoneal and other com plications and sequelw. It is essential that phy sicians appreciate the importance of early surgery, while a few patients for various rea sons may refuse operation, the majority will depend upon the attending physician for advice and accept the treatment which he advocates.
The mortality of the early operation, before the peri-appendicular structures have become involved, is nil; barring accidents, and the in cision in the rectus muscle can be so closely approximated that the abdominal wall is not weakened in the slightest by the operation. The peritoneum, the sheath of the rectus muscle and the skin, are usually sewed up in tier suture,— that is, in layers,— and the re sulting scar, about two inches long, can barely be perceived after the lapse of several years. As the disease progresses the mortality in creases in direct proportion to the extent to which the peri-appendicular structures have become involved. When an abscess de velops, the search for the diseased appendix is difficult and often dangerous, and many surgeons simply evacuate the pus cavity and establish drainage. But the presence of a necrotic appendix is a constant menace, fre quently causing secondary pus collections which may lead to a fatal termination. In all cases where pus is found the employment of drain age is imperative. This means that sterile gauze must be so disposed that the purulent material is caught up and carried off by capil lary drainage, thus forcing the abscess cavity to heal from the bottom upward, and avoiding The course of these cases is tedious and the convalescence prolonged. The complications incident to acute appendicitis with abscess are attended with great risk to lift The most dreaded is peritonitis with• invasion of the entire peritoneal cavity by the purulent and infectious products due to inward rupture of the abscess. Nearly every patient develop ing general peritonitis from an appendiceal abscess will die in spite of the most careful treatment and skillful operation. In advanced stages of the disease, when the appendix becomes necrotic and gangrenous, the cecum will frequently be implicated and be so diseased that the removal of the appendix cannot be fol lowed by closure of the wound in the cecum. In cases of this character gauze must be so placed as to isolate the fistulous opening from the general peritoneal cavity, with the hope that granulation will lead to spontaneous healing of the bowel opening; but this does not al ways follow, and in such instances the hole in the cecum becomes a fecal fistula, discharging the contents of the bowel through the wound in the side. Fistulae require very frequent dressing, heal slowly and are extremely annoy ing and disgusting to the patient. A third com plication which may result in abscess cases is intestinal obstruction. The manner in which adhesions form has already been described. They are nature's barriers against infection, but sometimes they prove a veritable boomerang. The author has more regard for the results of the aseptic scalpel of the surgeon administered at the opportune time than he has for nature's attempts at cure. It is well known that after burns of the hands the resulting scar tissue will cause contraction and deformity of the fingers. In the same way the adhesions by uniting the coils of intestines together to pre vent the spread of infection may encircle the bowel, and by contraction occlude its lumen, obstruct the flow of bowel contents and thus necessitate a second operation the mortality of which is quite high. Finally, if convalescence is uninterrupted and the wound heals slowly by granulation, the resulting scar is quite weak and nearly always produces a hernia (rupture).