The disease usually begins quite suddenly in the midst of perfect health; rarely it is preceded by slight digestive disturbances. The patient is seized with violent pains in the abdomen. These are felt at first either over the entire abdomen, in the epigastric region, or on the left side of the abdomen, but very soon they settle in the right iliac region. The pains are of an intense character, and occasionally are accompanied by paroxysms during which they are almost unbearable. Any motion increases the pain. The patient lies perfectly motionless and breathes superficially. The appearance is that of a 14 very sick person, the countenance manifests great suffering and anxiety. The temperature is usually considerably increased and continues so during the first days of the disease. The pulse is accelerated. Occasionally it is of small calibre, easily compressible, and at times irregular. The latter phenomena are found principally in critical conditions. A very frequent pulse and a comparatively low degree of fever are also considered bad omens. There is always complete anorexia and great thirst, the tongue is dry and thickly coated, the bowels, as a rule, are constipated. In rare instances there is diarrhoea.

According to Nothnagel, vomiting is present in almost three-quarters of the cases. It usually appears right at the commencement of the disease and lasts only a short time. In exceptional instances it persists for several days. The vomited matter consists of gastric contents, mucus, and bile. In very grave cases it exceptionally assumes a feculent character. The vomiting is occasionally accompanied by hiccoughs. Both these phenomena are very annoying and at the same time increase the pain through the motions evoked by them.

In many of the cases, soon after the commencement of the disease a tumor begins to form in the right iliac region. At first a rigidity of the muscles in this region is noted; later on a distinct resistance over an area of egg size may be found. The tumor is either circumscribed and sharply defined, or it is diffuse and connected with the neighboring tissues. The skin over the tumor is as a rule easily movable, while the latter is immovable. The tumor generally consists of a purulent exudation in and around the appendix and congested portions of the intestines, occasionally of the omentum, and of a purulent infiltration of the abdominal wall itself. In some instances the size of the tumor is considerably increased by an accumulation of fecal matter in the caecum. The tumor may be discovered by palpation and sometimes by percussion. Fluctuation is present only in very extensive abscesses. Its absence does not signify the absence of pus. The resistance as a rule increases either very slowly or quite rapidly. In rare instances, namely in those in which the abscess is surrounded by a firm capsule, it may remain unchanged for a long time. The abscess occasionally involves the muscles and even the skin lying above it.

The latter becomes infiltrated and oedematous, and in rare instances the abscess may spontaneously open through the skin. Occasionally the resistance disappears entirely when the purulent exudation has descended into the deeper parts. In such an event, by an examination through the rectum, and in females through the vagina, the exudation may be discovered filling Douglas' space.

In cases in which there is an extensive inflammation of the peritoneum accompanied by a considerable quantity of pus, severe pains in urination appear quite early, after two or three days (Fleischer). On this account the patients are often rather afraid to urinate. In the same cases there may also be paraesthesia and anaesthesia in the limbs, or obstinate erections of the penis, or a drawing up of the right testicle. These symptoms all show that the accumulation of pus presses upon the nerves of the sacral plexus.

The further course of the disease will largely depend upon the way in which the newly formed pus around the appendix acts. Often it leads to a perforation of the appendix. Sometimes the abscess forms adhesions and is encapsuled. Sometimes, again, the abscess penetrates into the peritoneal cavity and gives rise to diffuse septic or fibrino-purulent peritonitis.

Perforation of the appendix which occurs quite frequently in this class of cases is accompanied, according to Sonnenburg, by the following symptoms: The disease begins with febrile and marked symptoms; violent pains in the abdomen appearing either suddenly or after a short period of slight uneasiness and concentrating very quickly in the right side; vomiting accompanied by diarrhoea and in other cases by constipation; small and frequent pulse; fever commencing with chills and quickly rising; pronounced tympanites; general appearance extremely bad; slight cyanosis and perspiration; a distinct area of resistance over or around the affected spot. While all these symptoms are certainly found in cases of perforation of the appendix, they can by no means be absolutely relied upon; for they may exist in the same manner without a perforation taking place, and, on the other hand, the latter event may occur without any of the above-mentioned symptoms being present. For these reasons Boas 1 is reluctant to make the diagnosis of perforative appendicitis, and contents himself with determining the presence of purulent appendicitis.

Perforation peritonitis most often appears between the second and fourth days of the disease (Fitz). The danger of a penetration of pus into the free peritoneal cavity lessens with the length of time the disease has lasted, on account of the formation of adhesions. On the other hand, numerous other perilous events may take place. In some cases a few days after the commencement of the disease there is a subsidence of the most important symptoms (pains, fever, etc.), while in others they persist with undiminished severity. Even in the first class, however, the amelioration rarely persists, for pretty soon afterward the pains reappear and the fever recurs, and in connection with these symptoms the inflammation increases and the pus augments. Periods of improvement and exacerbation of the condition may alternate for quite a while until at last either recovery or a fatal issue ensues.

1 J. Boas: "Diagnostik und Therapie der Darmkraukbeiteu, "Leipzig, 1899.

A spontaneous cure or recovery without surgical intervention may occur in one of the following ways:

1. The abscess may become encapsulated, the pus losing its virulence and becoming absorbed. In such an event the tumor disappears and the patient is either definitely or apparently cured; for dangers to life remain after such a cure in consequence of the remnants of the abscess and of the adhesions formed among the intestines. "The occurrence of a sudden bursting of the abscess," using Ewald's words, "hangs like the sword of Damocles over the head of the patient as long as there is still pus present." In seemingly perfect health a fatal peritonitis may thus occur in patients who had previously suffered from an attack of appendicitis.

2. A cure may be established by the opening of the abscess into adjacent hollow viscera. Thus the abscess may open into the caecum, colon, small intestine, bladder, vagina, or pelvis of the kidney. This favorable issue is, however, rare.

3. The abscess may find its way externally by rupturing spontaneously through the skin. Sometimes, however, the pus burrows into other organs; thus it may reach the diaphragm (subphrenic abscess), and sometimes even force its way through into the pleural cavity and perhaps the lungs. But even from these places the pus may be evacuated spontaneously, principally through rupture into a bronchus and its expulsion during a coughing spell.

In a large number of cases peritonitis and septicaemia terminate the life of the patient; in others after recovery there are frequently grave recurrences of the disease.

Diagnosis

Catarrhal appendicitis can be diagnosed if there is a sudden onset of pain in the right abdominal cavity, principally in the region of the appendix, combined usually with a slight rise of temperature and some light gastric symptoms (nausea, anorexia, vomiting). The grave form of the disease or purulent appendicitis shows the same manifestations, only of a much severer type. Besides there are always present signs of serious illness. The patient is very pale and manifests an anxious appearance. Chills are frequently present and the temperature shows a certain irregularity in its course. There may be a marked rise in temperature after it has been quite low or almost normal for a time.

The presence of a tumor in the right iliac region is of great importance in the diagnosis of appendicitis, although this symptom is frequently absent. In order to recognize the nature of the tumor with regard to its contents, especially whether pus is present or not, Sahli first suggested the use of an exploratory puncture. If pus can be aspirated through the needle, then an abscess is positively present. Although many physicians make use of this method even nowadays, as for instance Leyden,1 Noth-nagel, Penzoldt,2 Fleischer, Boas, and others, most of the surgeons are decidedly opposed to this diagnostic measure (Fowler, Treves,3 Sonnenburg, and others). In this country the consensus of opinion is against the use of exploratory puncture, for its employment adds a new element of danger to the case, while its results, especially if negative, are unreliable.

1 E. von Leyden: Berl. klin. Wochenschr., 1889, No. 31.

2 Penzoldt: "Behandlung der Erkrankungen des Darms." Pen-zoldt-Stintzing's "Handbuch der speciellen Therapie innerer Krank-heiten, " Jena, 1896.

3 Treves: "On Peritonitis." British Medical Journal, 1894.

While appendicitis can usually be diagnosed without difficulty, in some instances its recognition is quite difficult. In cases in which the appendix is abnormally situated, as for instance in the left iliac region or in the upper part of the right abdominal cavity, the diagnosis of appendicitis' will hardly be possible.