Surgical Diseases

In a large proportion of all cases of acute appendicitis the following symptoms are present:

(1) Sudden pain in the abdomen, usually referred to the right iliac fossa;

(2) fever, often of moderate grade;

(3) gastro-intestinal disturbances—nausea, vomiting, and frequent constipation;

(4) tenderness or pain on pressure in the appendix region.

A sudden, violent pain in the abdomen is the most constant, first, decided symptom of perforating inflammation of the appendix. In fully half of the cases it is localized in the right iliac fossa, but it may be central, diffuse, but usually in the right half of the abdomen. Even in the cases in which the pain is at first not in the appendix region, it is usually felt here within thirty-six or forty-eight hours. It may extend toward the perinaeum or testicle. Some patients speak of it as a sharp, intense pain—serous-membrane pain; others as a dull ache—connective-tissue pain.

Fever is always present in the early stage, even in the mildest forms, and is a most important feature. The fever may be moderate, from 100^o to 102^o; sometimes in children at the very outset the thermometer may register above 103.5^o. Nausea and vomiting are symptoms which may be absent but which are commonly present in the acute perforative cases. Constipation is the rule, but the attack may set in with diarrhea, particularly in children.

McBurney has called attention to the value of a localized point of tenderness on deep pressure, which is situated at the intersection of a line drawn from the navel to the anterior superior spine of the ilium, with a second, vertically placed, corresponding to the outer edge of the right rectos muscle. Firm, deep, continuous pressure with one finger at this spot causes pain, often of the most exquisite character.

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 514-515.

Entered by: Erin Choi, 6/10/2020

Acute - Constipation, pain in the abdomen, and vomiting are the three important symptoms. Pain sets in early and may come on abruptly while the patient is walking, or more commonly during the performance of some action. It is at first colicky in character, but subsequently it becomes continuous and very intense. Vomiting follows quickly and is a constant and most distressing symptom. At first the contents of the stomach are voided, and then greenish, bile-stained material, and soon in cases of acute and permanent obstruction, the material vomited is a brownish-black liquid, with a distinctly faecal odor.

This sequence of gastric, bilious, and finally stercoraceous vomiting is perhaps the most important diagnostic feature of acute obstruction. The constipation may be absolute, without the discharge of either faeces or gas. Distention of the abdomen usually occurs, and when the large bowel is involved it is extreme. The face is pallid and anxious, and finally collapse symptoms supervene. The eyes become sunken, the features pinched, and the skin is covered with a cold, clammy sweat. The pulse becomes rapid and feeble.

Chronic - When due to faecal impaction, there is a history of long-standing constipation. There may have been discharge of mucus, or in some instances the faecal masses have been channeled, and so have allowed the contents of the upper portion of the bowel to pass through. In other instances there are vomiting, pain in the abdomen, gradual distention, and finally the ejecta become faecal. The hardened masses may excite an intense colitis or even peritonitis. The symptoms of obstruction are very diverse. There are transient attacks, in which from some cause the faeces accumulate above the stricture, the intestine becomes greatly distended, and in the swollen abdomen the coils can be seen in active peristalsis. In majority of these cases the general health is seriously impaired; the patient gradually becomes anaemic and emaciated.

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 522-523.

Entered by: Erin Choi, 06/10/2020

This is of interest in connection with the spontaneous rupture in cases of acute enlargement during typhoid fever or malaria, which is very rare. Rupture of a malarial spleen may follow a blow, a fall, or exploratory puncture [...]. Fatal hemorrhage may follow puncture of a swollen spleen with a hypodermic needle. Occasionally the rupture results from the breaking of an infarct or of an abscess. The symptoms are those of hemorrhage into the peritoneum, and the condition demands immediate laparotomy.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 881-882.

Entered by: Sonia Y. Khan, 7/7/2020