Chronic appendicitis may develop in one of several ways. It may commence insidiously, with indefinite and vague symptoms, so that the patient is unable to designate any stated time as the date of the beginning of his illness. It may follow a more or less frank attack of acute appendicitis from which the patient recovered by medicinal treatment or by surgical treatment, the appendix, however, not being removed.
In certain cases of the second variety the acute attack is partly recovered from, but the patient does not entirely regain his former health, and attacks of acute exacerbation occur from time to time. This is known as relapsing appendicitis. In other caws the patient apparently recovers his former health, and at long intervals —six months, a year, or more—other attacks occur.
This is known as recurring appendicitis. That recurrences are very frequent is indicated various statistics. Thus Nothnagel gives the percentage of recurrences in his experience as 16 per cent.; Rotter as 21 percent.; Sonncnburg as 32 percent.; and Sahli, from a collective investigation of 4593 cases from private practice, as 20.8 percent. Of 460 of my own cases, recurrences were noted in 312 (67.8 per cent.). The vast majority of recurrences develop within the first sue months; there are less within the succeeding six months.
During the following years the likelihood of recurrence becomes gradually less; recurrence may nevertheless occur after a great number of years. The number of recurrences that a patient may suffer is variable. Of the 312 patients previously referred to, 89 had two attacks, 52 had three attacks, 30 had four attacks, 18 had five attacks, 16 had six attacks, 6 had seven attacks, 2 had eight attacks, 2 had nine attacks, 4 had ten attacks, 1 had twelve attacks. 3 bad sixteen attacks, 2 had twenty attacks. The number of attacks that the remainder had is not known.
The symptoms of chronic appendicitis are most variable.
The most constant of all is pain, which is usually confined to the right fossa. It is of slight or moderate intensity, often persistent, and subject to acute exacerbation of minor intensity. The pain is increased by blows in the region of the appendix, by sudden exertion or undue exercise, and by the presence in the intestinal tract of indigestible food, which, by exciting increased peristalsis, leads to traction upon the eritoneal adhesion.
The acute attacks arc often of marked severity, incapacitating the patient for work and confining him to bed. At times the acute lesions may progress to acculturation and perforation of the appendix, with the development of a peri-perpendicular abscess or diffuse peritonitis, The symptoms of such attacks are those described in connection with acute appendicitis- At other times the acute exacerbation are relatively inconspicuous, and the pain is more or less dull and of unvarying intensity. One of my patients had constant pain for fifteen years.
Associated with the pain there is sometimes general debility and indisposition for work or exertion of any kind. There are often the indications of intestinal indigestion—abdominal fullness and distress, tympanists, borborygmi, coated tongue, capricious appetite, mucous diarrhea with alternate constipation, headache, malaise, hypochondria sis, etc. Neurasthenia is frequently a concomitant condition. Fever is usually absent. When present, it is of importance only when of the hectic type.
Palpation reveals more or less tenderness in the right iliac region. At times, even in the absence of much pain, the tenderness may be exquisite. In the majority of cases, if the tenderness be not prohibitive of deep palpation, an enlarged and thicken appendix can be made out. At times this can be rolled beneath the palpating finger as an inaugurated cylindrical mass. If there be much exudate and adhesions and especially if the omentum be adherent to the appendix, a distinct mass of rather large dimensions can be demonstrated by palpation. NoC infrequently palpation of a chronically inflamed, scmiquicscent appendix excites an acute exacerbation of the inflammation. This is especially likely to be the case if the appendix contain a focus of pus. If the latter be present tenderness on palpation is also likely to be more marked than when it is absent.
The danger attendant upon these chronic cases is their tendency to develop suddenly an acute exacerbation, which may go on to ulceration, perforation, gangrene, circumscribed or diffuse peritonitis, etc.
SUMMARY About What Does Chronic Appendicitis Do?.
- There is no constant relationship between the symptomatology and the pathological alteratioas.
- Of acute appendicitis there are “three cardinal symptoms” —pain, tenderness, and rigidity of the abdominal wall.
- The pain usually develops after eating. At first it fa colicky, and is referred to the epigastrium; later, it bocomes localized at the site of the appendix.
- Tenderness on pressure is always present, and is sometimes best clicitcd by rectal or vaginal examination. The point of greatest tenderness fa usually over the site of the appendix.
- The rigidity of the abdominal wall is usually right-skied. It follows the localization of the pain, and is most marked over the inflamed area.
- Vomiting is common at the onset of the attack. It desists in favorable cases. Its continuance is an unfavorable symptom.
- In chronic appendicitis the history is important. Localized pain and tenderness are the most constant symptoms. Palliation fa a most valuable means of diagnosis.