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McBurney had assisted Sands in a large number of cases, and in 1889 published his classical paper with an account of “The First Recorded Case where an Acutely Inflamed Appendix had been Removed while Full of Pus ” In the same year Weir also published an elaborate paper, making similar recommendations It is not necessary to follow the subject later than the year 1889, since to it every surgeon of note has probably contributed
Anatomy.
—The vermiform appendix is an embryonic relic, and, like all such remains, is not merely superfluous, but often troublesome. That at some time it may have had an ordinary function is not to be denied; that now, in quadrupeds at least, it has one cannot be successfully maintained. Its past importance may, however, be perhaps indicated by the fact that in the ostrich, for instance, it is said to assume a length of six feet. Because of its relatively wide variations in size, length, and emplacement, as well as because of its mesenteric and other anatomical arrangements, its affections are often complicated and variable in the symptoms they produce. The appendix is, in fact, a miniature intestinal tube, having the same structure as the small intestine, though but greatly reduced. Its average length should be 8 to 9 Cm., the shortest on record being 1 Cm., and the longest perhaps 24 Cm. Its average gross diameter should be that of a No. 16 French catheter, but it may be found 1.5 Cm. in size. The average diameter of its lumen should be 1 to 3 Mm. The appendicular artery is given off from the right colic branch of the ileocolic artery, and it ordinarily divides into four or five branches, according to the length of the appendix and the extent of its mesentery. It derives its nerve supply from the superior mesenteric plexus of the sympathetic ganglia, which itself is connected with the right pneumogastric, this fact explaining many of the reflexes accompanying its diseases. In it lymph abounds and lymph follicles are numerous. Around its neck, as around the origin of every other embryonic canal (as Sutton has shown), is found a collar of lymphoid tissue corresponding in structure to that seen in the pharynx. This tissue is inflammable, and succumbs easily to infection. Hence probably the apparent ease with which infection and gangrene occur in this locality. The position of the appendix is variable, and depends in effect on the development of the cecum and the degree of its rotation during this process. Its most frequent
location (40 per cent.) is behind the cecum. In 30 per cent. of cases it occurs on its anterior surface or just at its lower end. It may lie as a free pouch with a loose mesentery, movable in the abdominal cavity, or it may be essentially a retroperitoneal affair not only not free, but even difficult to find. In direction it may vary correspondingly. Thus it may lie behind the colon, perhaps pointing straight upward toward the liver; it may hang in the pelvis, it may point toward the sacrum, or it may coil up anteriorly; and, according to the extent and freedom of its mesentery, in any of these locations, it may either be unattached and movable or quite bound down. Again, it may lie nearly straight or it may be kinked, bent, or coiled. It is necessary that the surgeon appreciate these possible variations, for they account for vagaries in symptomatology. In brief it should lie in the iliac fossa, at least, and to the outer side of the iliac vessels, but it may hang over into the pelvis in 20 to 25 per cent. of cases, or its tip may rest in a pocket or even in a subcecal fossa. In other words, it may be found in almost any attitude or position, these variations being explainable by peculiarities of fetal development. Furthermore it may even have its own diverticula, as has been recently shown. Normally it should be practically empty, save perhaps for a little muddy mucus. Very frequently, however, it contains fecal matter, and upon this fact depends much of its importance. If from retained fecal matter fecal concretions gradually result, then these become irritants and may produce either appendicular colic or may predispose to acute infection. Upon the retention of fecal contents should depend also a miniature peristalsis, and imitation of what goes on in the intestine above, in the production of a genuine appendicular colic. How annoying, painful, or even disabling this may be may be learned from the history of many a patient. On the other hand the appendix may become gradually occluded or obliterated, in whole or in part. If this process begin at its distal end and involve the entire tube it might be considered a fortunate occurrence for the patient. If, however, it be due to previous inflammation, or to subinvolution of the previous process, and if fecal concretions be thus imprisoned, it is hardly desirable and will frequently lead to trouble. More or less occlusion occurs in probably at least one-fourth of mankind.
Like the bowel above, the appendix may suffer in various as well as in similar ways. Thus in it may be seen pathological conditions which involve the bowel proper. Tuberculosis and actinomycosis may even occur here as apparently primary lesions, while cysts have been discovered within its walls, and such tumors as fibromyomas or primary adenocarcinomas are also met here. I have seen three or four instances of primary cancer of the appendix, and have now living one patient from whom six years ago I removed an appendix and adjoining portion of the cecum involved in most distinct cancer. Again, the appendix participates in certain hernias and has been found in instances of strangulated or non-strangulated inguinal and femoral hernia, and has been seen also in cases of umbilical hernia. Twice I have found it in the inguinal canal and once in the femoral. Furthermore when diseased the appendix, like the bowel, may contract adhesions to certain viscera, while it is now well known that it may attach itself to the kidney, the bladder, the right ovary, the tubes, or the uterus. This is of more than mere passing interest, for by such adhesions cases are not only surgically complicated, but diagnosis is made difficult, because of associated symptoms pointing to the organ thus involved.
Foreign Bodies in the Appendix.
—Foreign bodies are occasionally found. This expression refers not merely to the fecal concretions above mentioned, which are practically small enteroliths. Thus, Kelly has mentioned cases in which ordinary pins have been found in this location, two of these cases being my own. In one instance I found the appendix to contain a round-worm at least three inches in length, and other intestinal parasites have been found by other observers. The laity have been greatly impressed by the reputed frequency with which grape and other seeds are found in the appendix, these figuring in their eyes as exciting causes of disease. In truth seeds are seldom found, that which has been mistaken for them being fecal concretions of various sizes and degrees of density I have found actual seeds two or three times, but probably not oftener.
Bacteriology of Appendicitis.
—Acute appendicitis being essentially an acute infection one inquires naturally which are the organisms most commonly involved.
Answer to this question should be sought rather in the text-books on pathology, and should be summarized here by simply saying that the colon bacillus is perhaps more often found in connection with these cases than any other one organism. Streptococci and staphylococci rank perhaps next in frequency, while the pneumococcus, the capsule coccus, and all of the other pyogenic forms may be present, either as contaminations or in almost pure cultures. The fauna and flora of the intestinal tract afford ample opportunities for contaminations with many forms of microbes. If pus found here be a pure culture of any one organism it is most often of the colon variety, which is known to vary much in virulence, even when occurring alone. Mixed infections, however, are more predominant and more serious, especially in proportion as the more active pyogenic organisms appear in greater numbers. The bacteriology of appendicitis is then of great pathological interest, but concerns the surgeon very slightly, unless he have to do with some peculiar form, such as pyocyaneus, or a particularly virulent streptococcus.
PLATE LI
Illustrating Various Degrees of Involvement of Appendix Vermiformis. (Richardson.)
A. Chronic, recurring.
B. Chronic, much thickened.
C. Acute, with necrosis and rupture.
D. Showing necrosis of mucous membrane.
E. Gangrene and perforation, permitting fecal extravasation.
F Total gangrene without perforation
Appendicular Colic.
—Sufficient has been said above regarding the appendix as a miniature intestine, its outlet guarded by the little valve of Gerlach, to afford an anatomical reason why conditions even in the larger bowel should be imitated here. Some writers have not placed as much stress upon appendicular colic as I would here. One sees many instances of it if he will only recognize it, the frequency of its occurrence not only disturbing the comfort of patients, but keeping ever before their minds the necessity for operation. An absolutely empty appendix will be free from all abnormal activity of this kind, but when a little fecal matter has become imprisoned, and when by its long retention fecal concretions have formed, they may give rise to considerable disturbance without actually producing inflammation, the former being due to the spontaneous effort of the appendix to expel them. This effort may be excited by other conditions in the bowel adjoining, but by itself it may be the essentially relatively violent muscular effort which produces pain and is followed by soreness. That not a few cases of acute appendicitis commence with an appendicular colic is extremely probable, and that it may occur at frequent intervals and never pass the colicky stage is equally true. Appendicular colic, then, may be a precursor of an infectious appendicitis, acting as a predisposing cause, or either may occur independently of the other.
Indications of this form of colic are frequent, viz., nagging pains in the region of the cecum, which may last a few moments or a few hours and then subside, leaving a tenderness which persists for a day or two, after which the patient seems to be free for a longer or shorter interval, to suffer again and again in the same way. These attacks may be accompanied by some nausea, will be found frequently associated with whatever may have disturbed ordinary intestinal activity, and may even produce a mild degree of fever, which latter is partly due to mental perturbation and partly to a mild degree of toxemia, the latter being possible in connection with abnormal appendicular activity, as the appendix itself is a closed sac and the very materials which it is trying to expel may furnish the toxins.
It is difficult to distinguish between appendicular colic and mild attacks of catarrhal appendicitis. The transitory nature of the former is its particular diagnostic feature, coupled with absence of all lasting indications.
The following would seem the simplest working classification of lesions of the appendix.
A. Acute.Catarrhal. Endo-appendicitis.
Diffuse. Parietal or interstitial.Hyperplastic. Obliterative Purulent.Intertubular Intramural.
Peri-appendicular.
Any of these may lead to Gangrenous or Perforative lesions
B Subacute Recurrent or relapsing
C. Adhesive or obliterative.
Almost any of the above forms may be associated with diseases of other abdominal viscera, as, for example, with typhoid. Thus out of 119 autopsies on typhoid patients 19 showed changes in the appendix corresponding to those produced by the typhoid organisms in other portions of the intestines. (Kelly.) Of 3770 autopsies on tuberculous patients tuberculous lesions were noted in the appendix
in 44 instances. The appendix may also become involved with any form of ileocolitis, either in the young or in the adult. Again an infection of the right tube and ovary may easily extend to and involve the appendix, just as infection may travel in the opposite direction. (See Plate LI.)
Before discussing the causes of this condition it is advisable to take a comprehensive view of the entire subject in its pathological relations. As Dieulafoy has shown, appendicitis is the consequence of the transformation of the hollow conduit into a closed cavity, whose length and narrowness make it liable to such changes, for which various causes are to be assigned: for example, the formation of calculi or concretions which are quite comparable to renal or biliary and which lead to a true appendicular lithiasis. There is even reason to believe that a calculous appendicitis may be hereditary and belong to the patrimony of gout. At other times it is the consequence of local infection, followed by tumefaction, and corresponding to obstruction of the Eustachian or the Fallopian tubes. Again it results from slow, progressive fibrous alterations or from the strangulations due to twisting or formation of adhesions. In any event the closed cavity varies in size and shape, and does not necessarily lead to self-destruction unless the bacteria thus pent up are sufficiently virulent. At all events the attack declares itself only when the cavity is actually closed, and it is then that imprisoned bacteria, previously harmless, multiply and intensify their virulence, as they do in a blocked loop of bowel. At times an acute intoxication from toxins is produced, and may be so pronounced that patients succumb to it almost before the characteristic lesions, or any local peritonitis, has become fairly outlined. On the other hand if retained bacteria be but slightly virulent, or have been successfully conquered by phagocytes, or if the canal has become pervious again, the attack may spontaneously subside, although there is great probability of recurrence. In many instances the infection ends in ulceration, abscess, gangrene or perforation, all of which may give rise to peritonitis of varying extent and severity. Germs may traverse the walls of an affected appendix without perforation. It may then become the direct cause of peritonitis, septicemia, or hepatic abscess.
Recurrent Appendicitis.
Every attack of appendicitis, no matter how mild, predisposes to a repetition of the trouble, in mild or in fulminating form. Every appendix once inflamed has had its blood supply compromised and may break down easily upon a second attack. While not every patient who has once suffered in this way should necessarily suffer again, the majority who have had one attack may have another. No one can be prophetic in this regard and no one may truly assert that several mild attacks may not be followed by another most severe. That an appendix has been once inflamed is sufficient to justify its subsequent removal. That it has been several times involved makes operation next to imperative. Even repeated attacks of appendicular colic predispose to trouble in this region. In any appendix which has in this way frequently excited suspicion, or which gives rise to frequently recurring though mild colicky pain and local tenderness, especially when coupled with mild stercoremia, indications are for removal. It may be safely laid down, then, as a rule, to which there should be few exceptions, that any appendix which causes frequently recurring or almost continuous trouble should be removed. —It is impossible in any brief summary to include all the possible causes of appendicitis. Those mentioned below are perhaps those most commonly recognized or pronounced, yet the list is far from complete. First of all it should be remembered that the disease occurs in a vestigial organ, containing relatively considerable lymphoid tissue, especially around its neck, that it is comparatively poorly supplied with blood, and that such tissue under such circumstances inflames easily and breaks down quickly. Doubtless the trouble in some instances commences within the tiny intestinal tube. At other times its originating cause lies without, as, for instance, when its blood supply is interfered with by pressure of an overloaded cecum, by tumors, or by violent intestinal activity; this especially in connection with an appendix firmly anchored and not freely movable, it being so fixed in many instances that it cannot readjust itself easily to varying conditions. Thus an overloaded cecum may first press upon the appendix and then by violence of activity so displace it that it may easily succumb. Again in those appendices which hang downward into the pelvis there is little or no
Causes.
drainage by gravity, and they may easily become overloaded. A movable kidney may also disturb the integrity of an appendix in certain locations. Foreign bodies frequently excite pernicious activity, especially fecal concretions, and actual calculi or miniature enteroliths. Traumatism sustains a certain relation to some cases of violent activity of the psoas muscles in athletes, which may upset the circulation of appendices which lie directly upon the muscles involved.
Many of the causes mentioned above are predisposing rather than actual. The actual exciting causes of acute infection have mainly to do with germ activity and with vascular supply. It is well known that the more virulent the organisms the more acute the resulting inflammation, and it is also well known that colon bacilli and the ordinary pyogenic organisms vary in virulence within wide limits, and that mixed are often more acute than simple infections. Typhoid bacilli, tuberculous bacilli and the like vary in the same way, and, in company with other germs, may easily light up serious disturbance. —Of the complications which may accompany or ensue upon appendicitis the most common are those which involve the peritoneum, either local or general. Acute peritonitis is to be feared not only because of its autotoxic expressions, but because of the acute obstruction which it may produce by gluing intestinal loops together and paralyzing their motility. When to more or less widespread peritonitis are added general sepsis, with all its possible complications, and such further local expressions as cellulitis, which may be pericolic, subphrenic, perineal, or pelvic, or phlebitis which, involving the portal system, would soon lead to formation of hepatic abscess, it will be seen how easily the case may become serious. Furthermore not only may the ovary and tube suffer, but cystitis and nephritis may occur as toxic complications, while finally, by violence of the ulcerative process, a fecal fistula may form. This is by no means a complete list, but includes some of the more frequent complications. Pain with nausea, tenderness, and rigidity constitute the triad of the most indicative early signs and symptoms, each of which needs to be considered by itself.
Complications.
Symptoms of Acute Appendicitis.
Pain. Tenderness.
—Pain is at the same time an important yet variable feature. In few other acute lesions does it vary as much in degree and location. Generally it is referred at first to the more central portion of the abdomen, as around the navel or between it and the right side of the pelvis. Later it may be localized at some widely distant point, as, for instance, far over upon the left side. Such vagaries may be held to be due to peculiarities of emplacement of the appendix, and would indicate that the organ will probably not be found in its most common location, but rather extending to the left or hanging over into the pelvis. When the appendix is attached to or lies near the bladder there may be considerable pain in the pelvis and in the bladder. It should be remembered that the parietal peritoneum is much more sensitive than the visceral, and in proportion as the lesion approaches the surface more exact information may be gathered from location of pain. Occasionally it may be referred to the region of the gall-bladder, or even to the chest above the diaphragm. In some instances it is agonizing, almost from the outset; in others it is never very severe. The rapidity of the process may be measured to some extent by the intensity and character of the pain. When the disease resolves slowly and kindly pain gradually subsides, but the sudden subsidence of pain, especially without equal improvement in other respects, is a bad rather than a good sign, indicating probably that perforation has occurred.
—Tenderness is a more constant and persistent and, therefore, a more reliable indication than pain, and, as well, less misleading. No matter where the patient may seem to feel pain the actual tenderness will indicate the location of the appendix itself. Thus even if pain on the left side be severe, tenderness will not accompany it, but will be found centred at the location of the appendix. This is a fact of great importance. In his first paper on appendicitis McBurney showed that the appendix is most commonly located at a point beneath a line drawn from the umbilicus to the anterior superior spine and one and a half or two inches away from the latter. This has since been known as McBurney’s point. To it, however, too much importance should not be attached, since the appendix is often not found under this area, and tenderness may be found at a distance two or three inches away from it. Over the
actually tender area the skin will also be hypersensitive, and this intense hyperesthesia is also an indication of considerable value.
Rigidity and Muscle Spasm.
—Rigidity and muscle spasm are to be carefully studied, and upon them much reliance may be placed. With the first onset of pain they may be general, but they usually become more and more localized, unilateral, and finally limited, save in those instances where general peritonitis has begun and is spreading. For instance, Richardson regards it in this light: “Rigidity with distinctly localized pain strongly suggests appendicitis; with fever it almost proves it; with tumor it fully establishes diagnosis.” When to ordinary abdominal rigidity is added actual muscle spasm, provoked by even light palpation, and occurring in the rectus or one of the flat muscles lying in close relation to the appendix, then a still more important indication has been obtained. When true muscle spasm involves all the abdominal musculature general peritonitis has probably begun.
Tumor.
—The presence of tumor in the suspected area will nearly always be a corroborative sign, but diagnosis should not depend upon its presence. It is hardly to be looked for during the early hours or perhaps days of an ordinary attack. It may be due to fecal impaction in the cecum, to outpour of exudate, to binding together of omentum and intestine, or to the presence of pus. If a considerable mass can be detected within the cecum during the early hours of an attack this should be regarded rather as an expression of coprostasis and impaction, to which the attack itself may be due. Tumor, therefore, is significant when present, while in some instances its absence is still more so.
Vomiting.
—Vomiting is an irregular and uncertain feature. Probably the majority of cases begin with nausea (after the initial pain) or with vomiting, either one without the other, or with both combined. Likely through the course of the disease vomiting may be an occasional disturbing element, though patients may have no nausea whatever.
Bowels.
—The condition of the bowels and their behavior will depend very much upon their actual state at the moment of attack. Some attacks seem precipitated by violent intestinal activity; here diarrhea or dysentery will be an early feature. Others are precipitated rather by overloading of the cecum; in these cases constipation would be a well-marked feature. Bowel inactivity is to some extent an
expression of bowel paralysis due to toxemia, which in some instances is profound, in others slight.
Temperature.
—The temperature is also a variable and uncertain feature. It may be normal at first or very high. At any time it may rise gradually or suddenly, and may subside in the same atypical way. Taken by itself it is an unreliable feature. When, however, temperature steadily rises the surgeon may take alarm, and if the pulse rate goes up correspondingly the case takes on a serious aspect. A sudden fall of temperature is almost as serious a feature as a sudden rise. A normal or subnormal temperature may be seen when a large amount of pus is present, or but a minimum of disturbance may be found when operating upon a patient whose temperature is 104°.
The Pulse.
—The pulse is a more reliable guide than any obtained with the thermometer, its rapidity being proportionate to the gravity of the disturbance. A constantly rising pulse is a serious indication, especially if accompanied by vagaries of temperature. Some operators regard the pulse as a sufficient indication for operation, holding that when it rises above 112 operation should be made. I hold this to be a good rule, but would not have it interpreted as indicating that operation should not be done unless the pulse attains this figure, and believe that, no matter what the other conditions, the final indication has arrived when the pulse goes above 112.
Abdominal Distention.
—Abdominal distention may be due to gas formation, to constipation, or may indicate the paralysis of peristalsis. When it becomes well marked it is a serious indication, and when toxemia is profound no sound whatever will be heard within the bowels thus distended. It usually indicates the onset of general peritonitis. It is unfortunate in more than one respect, since intraabdominal conditions are masked by it and operation complicated, it being sometimes impossible to restore the bowel to the abdomen without at least partially emptying it.
Jaundice.
—Jaundice, when occurring, is a toxic expression, possibly due to temporary obstruction of distended or paralyzed bowels.
Finally the general appearance of the patient will be suggestive, patients with serious conditions having always an anxious or
haggard facial expression, rarely moving themselves easily or freely in bed, or smiling at anyone or anything, their faces being perhaps somewhat flushed, their expression and action being apathetic, while perhaps later there will be delirium with restlessness. When the face is pinched, the eyes sunken, the nose sharp, the skin dusky, and respirations rapid and unsatisfying, as well as of thoracic type, any intra-abdominal infection may be regarded as serious and unpromising.
What shall be said about the value of the blood count? It is possible in nearly every instance to make a diagnosis of appendicitis without the aid of the microscope, as well as even to judge of the advisability of immediate or postponed operation. Nevertheless an indicative differential blood count, an affirmative result of the iodine test, or the discovery of indican in the urine, may afford positive corroboration in cases where doubt may have existed. In reality, however, any case which will furnish satisfactory and distinct responses to these tests should be recognized without them. A leukocyte count above 12,000, in connection with other indications, is usually sufficient to justify operation. A very high leukocytosis— e. g., above 24,000—is a matter of great importance. In the more chronic cases the leukocytosis is but slight.
Diagnosis.
—Obvious and indicative as many cases of acute appendicitis are from the outset, there are still others when one may be in serious doubt, even for some days, either because patients do not clearly state their own symptoms, because of peculiar reference of pain, or because of the co-existence of complications, each of which may mask the other.
Colitis of adults and enterocolitis of children will produce sometimes severe attacks of pain, with cramps and local tenderness, that may at first mislead. There is a form of mucous colitis which is now more generally recognized than in time past, in which diagnosis is sometimes quite difficult. The onset is often sharp, while the right iliac fossa may be occupied by an elongated, resistant, tender mass, showing fecal impaction within the cecum. On the other hand the same condition may be met in the left iliac fossa, and will thus indicate that the sigmoid is especially at fault. In these conditions there is often actual exudate around the inflamed bowel, and this
may even break down; it is proper then to speak of a circumscribed colitis, and there is reason to think that in certain cases it arises from infection of a diverticulum from the large bowel. The pain is not infrequently complained of at the so-called McBurney point. In not a few instances the appendix has been removed when under perfectly natural suspicion, and found so slightly involved as to show that the actual trouble was in the cecum rather than in the appendix itself. Dieulafoy believes, in fact, that formerly the cecum was made too much of and the appendix disregarded, while today these conditions are sometimes reversed.
From gallstone disease and cholecystitis its symptoms are sometimes quite difficult to distinguish. Especially is this true when pain is not accurately localized, and when, on the other hand, muscle spasm and tenderness are widespread. The previous history of the case will give much aid in this matter, while the pain in gallstone trouble radiates rather toward the right shoulder, in appendicular disease toward the umbilicus or downward. When dulness on percussion shades directly into liver dulness the gallbladder is naturally the more to be suspected. When patients themselves cannot make minute distinctions in description of pain and tenderness the condition may be difficult of recognition.
Peritonitis.
—The majority of all attacks of so-called idiopathic peritonitis spring from appendicular disease, at first and perhaps throughout unrecognized. A condition of peritonitis, then, for which other explanation is not found may be considered as, in all probability, due to appendicitis whose peculiar features may have been masked. It is not difficult to recognize a condition of general peritonitis. The great difficulty is to ascribe its proper cause. As already and elsewhere indicated these conditions merge into expressions of acute obstruction which still further complicate the case, and it is by no means infrequent to have this order of events: an acute gangrenous appendicitis followed by local peritonitis, with adhesions, which, becoming dense, rapidly produce obstructive symptoms, the condition going even farther and gangrene spreading from the appendix proper to any or all of those intestinal loops which come in contact with the primary focus, so that when the condition is
thoroughly revealed it is found to be one of multiple gangrene of the bowel as well as of fierce and septic peritonitis.
Gastric and intestinal ulcers with perforation are easily mistaken for appendicitis, especially when the duodenum is involved. In at least half of the recorded cases of perforating duodenal ulcer the condition has been at least at one time supposed to be one of acute appendicitis, while after perforation has occurred and the matter which has escaped has worked its way down toward the right iliac fossa the similarity of conditions will be all the more striking. If an accurate history can be obtained there will probably be learned from it that which will tend to avoid mistakes. The exceedingly abrupt and acute onset of symptoms will also be more pronounced than in most cases of commencing appendicitis. This is true also of the perforations of typhoid ulcer, especially of “walking typhoid.” While acute appendicitis during the course of typhoid is by no means unknown, the abrupt onset of pain, rigidity, and tenderness during the third week or later would suggest perforation very much more than the possibility of an appendical lesion.
Acute obstruction of the bowel due to other causes than appendicitis—e. g., volvulus or intussusception—might give rise to symptoms which would be regarded as indicating appendicitis. This is true also of strangulated hernias, especially the internal forms, since there will be no excuse for failing to discover an external strangulation of this kind. Lead colic may simulate some of the milder and more chronic forms of appendicitis, from which it should not be difficult to exclude it by its history, the occupation of the patient, and the appearance of the gums.
The kidneys and ureters are sometimes so involved as to occasion doubt. A floating kidney, with its possible crises, displaced into the right iliac fossa, where it might be mistaken for an inflammatory mass, might thus cause some hesitation. So also might the acutely suppurative forms, the formation of a sudden phlegmon about the kidney, or the entanglement of a calculus, either at the hilum or along the ureter, produce severe pain, tenderness, and fever, which would at first easily perplex. The pain of renal colic, however, is usually more agonizing, beginning in the flanks and referred down along the ureters to the genitals and the inner side of the thigh. It may also be
intense in the back, and may be accompanied by nausea and vomiting. Renal colic is also nearly always accompanied by frequent urination and sometimes by the appearance of blood in the urine. With an impacted calculus at the lower end of the ureter at the level of the appendix diagnosis may be very difficult. Here the x-rays may afford some assistance.
Acute pancreatitis begins with intense abdominal pain that may at first suggest appendicitis. The pain, however, is usually epigastric; abdominal distention comes on early; vomiting may be profuse, and the tenderness is most marked along the left costal border There is, moreover, a more profound prostration, sometimes accompanied by cyanosis. An acute suppurative pancreatitis may soon be followed by peritonitis, which when seen will so completely mask all symptoms that diagnosis as between the two is quite impossible, but symptoms which can be accurately localized will usually point to the upper rather than to the lower abdomen.
Mesenteric thrombosis and embolism are rare conditions which commence usually with fulminating symptoms and produce intense agony, with tenderness and rigidity all over the abdomen. Their onset is so profound that patients fall into a condition of extreme collapse within the first few hours, and their tendency is so rapidly to the bad that they are not likely to be mistaken for acute appendicitis.
The pelvic viscera of women also furnish acute inflammations, such as pyosalpinx, with or without rupture, that sometimes precipitate very acute symptoms which may point to the abdomen rather than to the pelvis. In many of these instances the appendix is more or less adherent to the adnexa on the right side, and infection in either one may easily travel to the other, so that both become ultimately involved. Local examination will reveal the existence of pelvic conditions, in whose absence there may be justification for inferring that the trouble has not originated in that cavity.
Ruptured extra-uterine pregnancy has been in numerous cases mistaken for acute appendicitis. It usually begins with violent pain and pronounced muscle spasm, with more or less shock. I have repeatedly been called to operate for appendicitis and found the other condition present. The operator may be prepared to find it if he elicit a suggestive history or if a vaginal examination reveals a pelvis
more or less filled with semisolid material. Amenorrhea does not always signify ectopic gestation, yet when doubt arises it would be advisable to inquire carefully into the menstrual habit of the patient. On the other hand it is known that acute appendicitis may bring on uterine hemorrhage. When, however, the possibility of pregnancy exists, along with a history of menstrual irregularity, or of hemorrhages unaccounted for, and one finds within the pelvis the uterus pushed forward or displaced, or perhaps an irregular tumor, he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis occurring during pregnancy, or still worse, as I have seen it, e. g., in a woman with a large uterine myoma, gone to about the seventh month of pregnancy, and then suffering from an acute periappendicular abscess, the whole proving more than she could withstand.
With an appendix placed behind the cecum it will usually rest upon the psoas muscle, where it may be disturbed by violent exercise, or where it may lead to mistaken diagnosis either in case of acute inflammation of the muscle itself or of acute appendicitis. When the right limb is drawn up, and especially when all motions of the limb give pain, we may believe at least in the participation of the muscle in the inflammatory activity. On the other hand, an insidious psoas abscess may give rise to a certain degree of tenderness in the right iliac fossa, with flexion of the thigh, and gradual development of tumor, which may be mistaken for chronic appendicitis.
The possibility of appendicitis occurring during typhoid has been mentioned. Differential diagnosis between the two conditions will ordinarily not be difficult when one can obtain an accurate history. In classical appendicitis pain is always the first symptom, and temperature rarely rises until a number of hours at least after the first attack of pain. Even the milder typhoid cases may show tenderness in the right iliac fossa, but one should look for the characteristic eruption and make a Widal test. The presence of splenic enlargement would point to typhoid, as would also the occurrence of bronchitis, epistaxis, or headache, with perhaps albuminuria. The most perplexing cases will be those of perforation, perhaps even of
typhoid ulcer of the appendix In these cases acute pain will usually indicate perforation.
Intrathoracic affections sometimes begin with or are accompanied by severe pains which are referred to various parts of the abdomen and cause great confusion. Thus I have repeatedly seen pneumonia, even on the left side, regarded at least at first as acute appendicitis, because patients referred most of their pain to the abdomen rather than to the chest, while the abdominal muscles participated to such an extent as to produce pronounced rigidity. Here a blood count would scarcely help, but careful physical examination of the chest would reveal the difficulty. Such examinations should be made when respirations become irregular, or when the breathing is evidently in any way embarrassed. Acute pneumonia and acute pleurisy, especially diaphragmatic, may have then to be differentiated from acute appendicitis.
Finally, hysteria is an element not to be disregarded in some of these cases; not that it is likely often, if ever, to lead to serious doubt, but that patients with the hysterical or neurotic temperament are constantly tempted to so seriously exaggerate their complaints as to lead to at least a more serious view regarding themselves than circumstances justify. Thus a mild appendicular colic in a neurotic patient may produce a disproportionate complaint, and one must be ready to assign to hyperesthesia or exaggerated complaints their proper value.
The symptomatology of appendicitis may then be summarized briefly as follows: When pain comes on suddenly and is referred to the lower part of the abdomen, or even its central region, becoming perhaps more localized as the hours go by, is shortly followed by nausea or vomiting, and this by general abdominal sensitiveness, with an increasing degree of rigidity; and when temperature, which at first is not elevated, begins to rise in from twelve to twenty hours, then it may be held that this is a classical picture of an attack of acute appendicitis. So strongly does Murphy, for instance, hold to this order of events that he even questions diagnosis when symptoms are not thus timed, and especially if vomiting precede pain.
When pain which has been severe subsides, and comes on afresh after an interval of perhaps thirty-six hours, it is to be regarded as due to fresh peri-appendicular involvement, and is an unfavorable feature. In fact the subsidence of pain and apparent improvement often noted do not always mean actual improvement, but may be the forerunners of a still more dangerous condition. Thus the “perilous calm” of appendicitis should hasten operation, or at least increase watchfulness, rather than beget confidence. Should one rely too much upon them and procrastinate he will find that his mortality rate will rise accordingly The statement elsewhere quoted in this work that “the resources of surgery are rarely successful when practised upon the dying,” will apply here.
There is scarcely any equally limited area of the body in which as many varied and widely different pathological conditions may be exemplified as in the appendix and the space immediately around it. The mildest degree of hyperemia or vascular engorgement, the most destructive form of inflammation, with fulminating necrosis, may here be observed. Moreover, conditions commencing under one type may quickly change and the whole type of an attack may within a short time be merged from the mildest into the most severe.
In catarrhal or endo-appendicitis it is mainly the mucosa which suffers. This may undergo merely a congestion, with increase of discharge, and, so long as the outlet be not completely obstructed, may be a purely temporary matter of but a few hours’ duration, or it may extend over a few days. The purulent or more destructive forms may commence in either of the coats of the appendix. It is no uncommon thing to find a necrotic mucosa with a still unbroken serosa, or a perforation of the outer coats and a hernial protrusion of the inner, perhaps just ready to give way. In location and extent the suppurative and destructive process may also vary. Whereas ordinarily the distal portion, being less supplied with blood, will suffer first, it is not uncommon to find perforation at the junction of the appendix with the cecum, or even gangrene of a limited area of the cecal wall itself. Again, at times, the trouble seems limited to accumulation of pus within the appendix, i. e., an empyema of the appendix, without great tendency to involve the structures adjoining, and an appendix may be found containing a few drops of pus or
