The above symptoms are those relied upon in making a diagnosis, and especially the first four—pain, tenderness, rigidity, and nausea with vomiting—which are generally referred to as the four cardinal symptoms. Some authors give a "characteristic triad," namely: pain with tenderness of the abdominal wall, fever, and vomiting.
A patient may have pain with tenderness, fever and vomiting, and be very far from having appendicitis. There is a world of difference in the importance of pain, the range being from no danger at all to absolutely no hope. Tympanites may mean a very simple state or an absolutely hopeless state. To be able to interpret the exact worth of symptoms means observation, study, reflection—labor and experience running over years—and a love of work that is not the good fortune of a very large percentage of mankind.
Before we get through with this subject the reader will be shown how it is possible for highly educated men to be wholly unable to interpret the worth of symptoms.
CHAPTER VI
_Surgical Treatment: _Appendicitis is quite generally thought of as an exclusively surgical disease. Osler recommends that such cases be operated upon, and most of the prominent physicians agree with him. The surgeons are a unit for the operative treatment.
Many surgeons are in accord with Prof. L. ID. Russell of Cincinnati, O., namely, that it is not a question of "when to operate, but how much to operate," meaning that all cases should be operated upon as soon as possible after the diagnosis has been made, but the extent of the operation is to be decided by the conditions found after the incision has been made. If the appendix is surrounded with pus and hard to get at, the indication is merely for drainage at this operation, but if the appendix is accessible, it should be removed.
Ochsner recommends the withdrawal of all food by mouth, washing out the stomach, leeches to be applied on the abdomen over the inflammation to relieve pain, rectal feeding, and operation in every case after the acute attack is over. If a "competent surgeon" is available he thinks the proper thing to do is to operate during the acute attack, except in a class of very severe cases, which, he says, have a better chance to recover without the operation. I will quote a few paragraphs from his book, setting forth his views:
"Taking into consideration the pathological conditions described, together with the clinical experience, the likelihood of a recurrence after an attack if no operation is performed, and the likelihood of a complete and permanent recovery if the diseased organ is removed under favorable circumstances, we can come to but one conclusion, namely, that if the desired condition can be obtained the diseased appendix should be removed."
"Except in very rare cases in which the entire mucous membrane of the appendix is destroyed during the first attack, it is doubtful whether the patient ever completely recovers unless the appendix be removed. It is more likely, from an anatomical and pathological standpoint, and certainly more in accordance with my clinical observations, that the patient usually suffers from disturbance of his digestive apparatus after recovering from an acute attack of appendicitis."
" Mynter does not deny the possibility of complete recovery from appendicitis without removing the organ, but considers it an exception or almost an impossibility, and I find that this view is shared by a majority of clinical observers of wide experience."