The principles and practice of modern surgery

by Roswell Park

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 gall-bladder 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.