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 intra-abdominal 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.