John B. Deaver says the important points that have to be learned about
this disease are that it is the most common intra-abdominal
inflammation; that indigestion is often a forerunner, preparing the soil
for the infection; that being an infectious disease and the most common
infectious disease of the abdominal cavity, the appendix constitutes the
avenue by way of which infection most commonly invades the upper
abdomen. He considers acute appendicitis from the anatomical,
etiological, bacteriological, and pathological standpoints: the points
of the latter touched upon chiefly are in connection with peritonitis
and abscess. The portions of the peritoneum most susceptible to
infection are the diaphragmatic and enteronic. The differential points
between a diffuse and a localized peritonitis are that in the former the
pain is greater, the abdominal breathing more restricted and the
rigidity and tenderness embrace a greater area of the overlying
abdominal wall; upon auscultation the peristaltic waves are heard over a
greater area and the abdominal breathing is less marked in the diffuse
than in the localizing variety. In the early stages the tenderness and
rigidity are best elicited by slight pressure. If the symptoms and
signs, namely, pain, vomiting, fever, tenderness, and rigidity are
interrupted, the diagnosis of acute appendicitis may be considered
doubtful. Leucocytosis is of value as a confirmatory symptom when the
patient reacts well to the infection. The most important point in the
differential diagnosis is the distinction between acute cholecystitis
and acute appendicitis. Acute pancreatitis, perforated ulcer, or
perforated gall bladder, present symptoms so much more intense than
those of acute appendicitis that they should not give rise to confusion.
As to the treatment, the writer states most emphatically that in all
cases of acute abdominal pain nothing in the shape of a purgative or
aperient medicine should be given until the cause of the pain is
understood. In his experience purgatives play the greatest amount of
havoc in acute abdominal conditions; 90 per cent of cases of perforating
peritonitis have been purged. In the presence of peritonitis and in the
absence of operation the patient should be set up in bed, given nothing
by mouth, not even cracked ice; he should be given enteroclysis by the
Murphy method and have an icebag over the site of rigidity and
tenderness; the icebag is useful to prevent the doctor from making too
many examinations and for its local anesthetic affect. The idea that it
has any effect in controlling inflammation is fallacious. In diffuse
peritonitis, in the absence of peristalsis and of a definite point of
localization, it is the writer’s practice to defer operation until the
peritonitis becomes a localized or localizing one. The principles of
anatomical and physiological rest, assisting the functions of the
peritoneum, absorption and exudation, are defeated by any treatment
other than the foregoing.—_Medical Record._