Mesenteric thrombosis and embolism are rare conditions which commence usually with fulminating symptoms and produce intense agony, with tenderness and rigidity all over the abdomen. Their onset is so profound that patients fall into a condition of extreme collapse within the first few hours, and their tendency is so rapidly to the bad that they are not likely to be mistaken for acute appendicitis.
The pelvic viscera of women also furnish acute inflammations, such as pyosalpinx, with or without rupture, that sometimes precipitate very acute symptoms which may point to the abdomen rather than to the pelvis. In many of these instances the appendix is more or less adherent to the adnexa on the right side, and infection in either one may easily travel to the other, so that both become ultimately involved. Local examination will reveal the existence of pelvic conditions, in whose absence there may be justification for inferring that the trouble has not originated in that cavity.
Ruptured extra-uterine pregnancy has been in numerous cases mistaken for acute appendicitis. It usually begins with violent pain and pronounced muscle spasm, with more or less shock. I have repeatedly been called to operate for appendicitis and found the other condition present. The operator may be prepared to find it if he elicit a suggestive history or if a vaginal examination reveals a pelvis more or less filled with semisolid material. Amenorrhea does not always signify ectopic gestation, yet when doubt arises it would be advisable to inquire carefully into the menstrual habit of the patient. On the other hand it is known that acute appendicitis may bring on uterine hemorrhage. When, however, the possibility of pregnancy exists, along with a history of menstrual irregularity, or of hemorrhages unaccounted for, and one finds within the pelvis the uterus pushed forward or displaced, or perhaps an irregular tumor, he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis occurring during pregnancy, or still worse, as I have seen it, e. g., in a woman with a large uterine myoma, gone to about the seventh month of pregnancy, and then suffering from an acute peri-appendicular abscess, the whole proving more than she could withstand.
With an appendix placed behind the cecum it will usually rest upon the psoas muscle, where it may be disturbed by violent exercise, or where it may lead to mistaken diagnosis either in case of acute inflammation of the muscle itself or of acute appendicitis. When the right limb is drawn up, and especially when all motions of the limb give pain, we may believe at least in the participation of the muscle in the inflammatory activity. On the other hand, an insidious psoas abscess may give rise to a certain degree of tenderness in the right iliac fossa, with flexion of the thigh, and gradual development of tumor, which may be mistaken for chronic appendicitis.
The possibility of appendicitis occurring during typhoid has been mentioned. Differential diagnosis between the two conditions will ordinarily not be difficult when one can obtain an accurate history. In classical appendicitis pain is always the first symptom, and temperature rarely rises until a number of hours at least after the first attack of pain. Even the milder typhoid cases may show tenderness in the right iliac fossa, but one should look for the characteristic eruption and make a Widal test. The presence of splenic enlargement would point to typhoid, as would also the occurrence of bronchitis, epistaxis, or headache, with perhaps albuminuria. The most perplexing cases will be those of perforation, perhaps even of typhoid ulcer of the appendix. In these cases acute pain will usually indicate perforation.
Intrathoracic affections sometimes begin with or are accompanied by severe pains which are referred to various parts of the abdomen and cause great confusion. Thus I have repeatedly seen pneumonia, even on the left side, regarded at least at first as acute appendicitis, because patients referred most of their pain to the abdomen rather than to the chest, while the abdominal muscles participated to such an extent as to produce pronounced rigidity. Here a blood count would scarcely help, but careful physical examination of the chest would reveal the difficulty. Such examinations should be made when respirations become irregular, or when the breathing is evidently in any way embarrassed. Acute pneumonia and acute pleurisy, especially diaphragmatic, may have then to be differentiated from acute appendicitis.
Finally, hysteria is an element not to be disregarded in some of these cases; not that it is likely often, if ever, to lead to serious doubt, but that patients with the hysterical or neurotic temperament are constantly tempted to so seriously exaggerate their complaints as to lead to at least a more serious view regarding themselves than circumstances justify. Thus a mild appendicular colic in a neurotic patient may produce a disproportionate complaint, and one must be ready to assign to hyperesthesia or exaggerated complaints their proper value.
The symptomatology of appendicitis may then be summarized briefly as follows: When pain comes on suddenly and is referred to the lower part of the abdomen, or even its central region, becoming perhaps more localized as the hours go by, is shortly followed by nausea or vomiting, and this by general abdominal sensitiveness, with an increasing degree of rigidity; and when temperature, which at first is not elevated, begins to rise in from twelve to twenty hours, then it may be held that this is a classical picture of an attack of acute appendicitis. So strongly does Murphy, for instance, hold to this order of events that he even questions diagnosis when symptoms are not thus timed, and especially if vomiting precede pain.
When pain which has been severe subsides, and comes on afresh after an interval of perhaps thirty-six hours, it is to be regarded as due to fresh peri-appendicular involvement, and is an unfavorable feature. In fact the subsidence of pain and apparent improvement often noted do not always mean actual improvement, but may be the forerunners of a still more dangerous condition. Thus the “perilous calm” of appendicitis should hasten operation, or at least increase watchfulness, rather than beget confidence. Should one rely too much upon them and procrastinate he will find that his mortality rate will rise accordingly. The statement elsewhere quoted in this work that “the resources of surgery are rarely successful when practised upon the dying,” will apply here.