In describing the symptomatology of appendicitis it will again be best to differentiate the two forms already mentioned above, namely, the catarrhal and the severe form.

1. Catarrhal Or En Do-Appendicitis

An attack of appendicitis is usually characterized by a sudden appearance of pain in the abdominal cavity, which at first may be diffused or in the region of the navel, but very soon is localized in the right iliac region. A moderate rise of temperature is very frequently present. Slight gastric symptoms, nausea, and sometimes vomiting often occur, but are, as a rule, only transient. The pains usually increase in intensity, and the patient assumes a fixed position with the legs flexed. Any change in the position or any movement of the thighs increases the pain. Examination by palpation shows extreme tenderness on pressure of the right iliac region, more especially at McBurney's point, while the rest of the abdomen can be examined by pressure without giving rise to the slightest pain. While the pains are generally continuous, they may show periods of exacerbation. The latter, according to Nothnagel, are most probably due to a spastic contraction of the muscles of the appendix.

The term "appendicular colic " has been given by Tala-mon to the same condition. Talamon, however, assumed that the colic is always due to an attempt of the appendix to rid itself of a fecal concretion. Inasmuch as operations for appendicitis have often been performed during the attack of colic and no fecal concretions whatever found in the appendix, and inasmuch as coproliths have been found in cases in which no colic whatever existed, this theory cannot be maintained.

In some cases there is an area of resistance in the right iliac region. If the latter be due to an accumulation of fecal matter in the caecum, the tumor can be slightly moved and its shape changed by pressure. In a few of the cases of catarrhal appendicitis the resistance is due to an inflammatory swollen (serous) condition of the appendix and of the neighboring organs. In this instance the tumor is not circumscribed but rather diffuse, immovable, and its shape unaffected by pressure.

In comparatively few cases can the appendix be directly palpated. It then appears as an elongated round body of the size of the little finger, and is very painful on pressure. The examination of the appendix itself, whenever this is possible, is certainly of the utmost importance for diagnosis. Edebohls 1 deserves much credit for having cultivated and perfected the method of examining the appendix by palpation. According to Edebohls, this examination is best done as follows: The patient lies upon his back with the legs comfortably flexed. The physician standing at the patient's right begins to search for the appendix by applying two, three, or four fingers of his right hand, palmar surface downward, almost flatly upon the abdomen at or near the umbilicus; while now he draws the examining fingers over the abdomen in a straight line from the umbilicus to the anterior superior spine of the right ilium, he notes successively the character of the various structures as they come beneath and escape from the fingers passing over them. In doing this the pressure exerted must be strong enough to recognize distinctly along the whole route traversed by the examining fingers the resistant surface of the posterior abdominal wall and of the pelvic brim.

Only in this way can we positively feel the normal or slightly enlarged appendix. Pressure short of this must necessarily fail.

1 Edebohls: American Journal of the Medical Sciences, May, 1894.

R. T. Morris 1 suggests for Edebohls' method of palpating the use of three right-hand fingers to feel with and three left-hand fingers placed upon these to press with. The fingers that are to do the feeling are pressed by means of the three others down to the border of the right rectus ab-dominalis muscle at the level of the navel and slowly drawn toward the examiner. I have found both these methods very useful in detecting the position and size of the appendix.

The temperature is usually but slightly raised, sometimes even normal. The pulse likewise is either normal or but moderately accelerated.

Constipation is often present, but seems to be rather the result of the inflammatory condition of the appendix than its cause, as was formerly believed. In a comparatively small number of cases diarrhoea is present during the attack of appendicitis.

Course

An acute attack of catarrhal appendicitis may last from two to three days to two to three weeks. After this variable period of sickness the symptoms either entirely disappear or persist in a slight degree. With regard to the further development the following classes must be distinguished: 1. There may be complete recovery without any further trouble. 2. The patient may entirely recover from the present attack, but have a return of the disease after a variable period of time (from a few weeks, a few months to a year or two) - "recurrent appendicitis." 3. The symptoms may not completely disappear but may persist for many weeks and the patient may remain in a lingering condition - "subacute or chronic appendicitis."

1 R. T. Morris: "Lectures on Appendicitis," New York, 1899, p. 45.

The first class of perfect recoveries is comparatively small. In this group there is either an obliteration of the appendix or the catarrhal process may have subsided completely without having left behind any lesions. The second class of recurrent appendicitis comprises the majority of the cases. In these a chronic catarrhal condition of the mucosa of the appendix may persist without manifesting symptoms until a new invasion of micro-organisms gives rise to an acute exacerbation of the process, or strictures of the lumen of the appendix may have formed as a consequence of the acute attack and thus become the cause of renewed disturbances later on. In the third category the catarrhal appendicitis has led to severe anatomical lesions. There may be a considerable thickening of the appendix wall including the serosa. The appendicular lumen may show ulcerations, strictures, or bends. There may also be an accumulation of pus (py-appendix).