[Illustration: Large Intestine showing Vermiform Appendix (v.a.) and Caecum (c)]
On paper it is easy to arrange cases of appendicitis into three classes--catarrhal, ulcerative and mortifying--but in actual practice this is neither desirable nor possible. Such classification is based upon the symptoms, and in appendicitis symptoms may be actually misleading. The three conditions to which the surgeon chiefly looks for guidance are the aspect of the patient, the rate of his pulse and the degree of fever as shown by the thermometer. But in certain cases of appendicitis, though the surgeon knows intuitively, or, at least, suspects, that the general condition is extremely serious, the patient looks fairly well and says that he is not in pain, his pulse-rate being but little quickened and his temperature being but slightly above normal. Nevertheless, when the surgeon has opened the belly in the appendix region, he finds the appendix swollen, perforated and mortified, and lying in a stinking abscess, whilst inflammation has already spread to the neighbouring coils of intestine. Unfortunately, the surgeon can no more tell what he is going to find at his operation in some of these cases than he can foretell the course which any particular case is going to run.
We may most usefully give here the symptoms as they are likely to be found in an ordinary case of appendicitis, and as they may be observed by one who is not a member of the medical profession, in a way that may prove helpful to him when circumstances have awakened his interest in the disease.
The case taken shall be that of a boy at school, for, as already stated, boys are more prone to the disease than girls. The boy has had, may be, occasional attacks of "indigestion" which have duly passed away under the influence of aperient medicines, and, being heated at play, he has sat down upon the cold ground. Or he has got wet through or over-tired during a long walk or ride. At any rate, his vital powers have been suddenly lowered, and the micro-organisms teeming in his bowel have seized upon the lining membrane of the appendix. He feels out of sorts, and if he manages to eat a meal he very likely vomits it soon after, for the whole nervous system of his abdomen is disturbed by the local inflammation. The act of vomiting gives slight relief, however, and probably he begins to complain of pains in his head as well as in his abdomen, and possibly he has an attack of shivering--the result of disturbance of his general nervous system. By this time he may be attacked with intense pain in the part of his abdomen a little above the middle of the right groin, and at that spot there may be a tenderness, and a feeling of resistance may be made out by the gentle pressure of the finger. In order to relax the pressure upon the tender area he probably lies with his right thigh slightly bent. By this time he may look ill, his face being slightly flushed, or pale and anxious. If the clinical thermometer is placed under his tongue, the index may rise a degree or two, perhaps several degrees, above normal, and his pulse may be quickened to 90 or 100 beats a minute. Perhaps it is a good deal quicker than this. Later, the skin of the lower part of the right side of the abdomen may be flushed or reddened.