APPENDICITIS

experience during the period 1910-26 has shown quite definitely the extent to which inflam- mation of the appendix is prevalent. many valuable lives are needlessly lost from appendicitis every year, chiclly due to ignorance and delay in diagnosis and treatment. the significance of abdominal pain, especially in children, is not sufficiently recognised by the public. time is wasted on purgatives and sedatives, both of which do much harm, for the former precipitate perforation and hasten the spread of the disease; and the latter, by relieving pain, mask the symptoms and often lead to fatal delay in treatment. no one can tell whether an attack is going to subside under medical treatment or proceed with great rapidity to a fatal issue. the risk of immediate operation is practically negligible, whereas that of waiting is great and uncertain. the experience of sur- geons all over the world shows that there is practically no mortality from operations for appendicitis undertaken within 12 or even 24 hours of the onset of the attack, whereas the death- rate for operations delayed until the third or fourth day is about 10%. when the inflammation is limited to the appendix there is little risk in operation, but the complications of the disease are very grave. fortunately they take time to develop and therefore can be avoided by operating sufliciently early. there are many different degrees of appendicitis such as: (1) appendical colic, due to intermittent obstruction of the appendix and usually associated with no signs of inflammation, such as fever: (2) acute appendicitis, which varies in degree from the mildest inflammation to gangrene or mortification with perforation of the appendix, causing local or generalised peritonitis: (3) chronic appendicitis or “ appendix dyspepsia.”’ here chronic inflamma- tion of the appendix leads to irregular spasm and flatulent dis- tension of the stomach and intestine with nausea and vomiting, a condition often mistaken for gastric or duodenal ulcer. symptoms.—-the most important symptom of acute appendi- citis is the sudden onset of severe pain in the middle of the abdo- men, settling later in the right flank, above the groin. here a medical man, who should be called at once, will find superficial and deep tenderness and rigidity and fixation of the abdominal wall, the significance of which 1s unmistakable. when the ap- pendix is misplaced, so are the local signs. the pulse and tem- perature usually rise, but unfortunately they may sometimes remain normal, or suddenly fall below it, in grave cases. a falling temperature and a rising pulse are of the greatest significance. other symptoms are nausea and vomiting, a flushed face and furred tongue; a rigor is not uncommon. instead of constipa- tion there may be diarrhoea and irritability of the bladder from spread of the inflammation. either local or general swelling of the abdomen is usual in late cases and sometimes an abscess may point and even discharge on the skin or into the bowel. diagnosis.—this depends chiefly upon the detection of local tenderness and rigidity in the right flank and the presence of fever and a quickening pulse; indiscretions of diet, although they may cause vomiting, do not give rise to these signs. palliative treatment.—when symptoms suggestive of acute appendicitis develop it is of vital importance to put the patient to bed and give him nothing but water until the diagnosis has been made and an operation can be performed. when, for some reason, an operation cannot be performed, complete rest and careful diet must be continued until the attack has subsided. 148 only liquids are given by the mouth, and purgatives and sedatives are entirely avoided; but local sedatives, such as moderate heat, may be applied to the abdomen. operation.—it 1s a common mistake that the patient needs elaborate preparation for an operation for appendicitis, but fortunately this is not the case, and the rapid progress of an acute attack will not allow of it. a valvular incision, which should icave no weakness of the abdominal wall, is made over the site of the appendix; the latter is removed and the wound completely closed except in late cases, when abscess or peritonitis has developed, in which temporary drainage may be necessary. in very late grave cases with abscess formation, the surgeon has sometimes to be content with mere drainage, deferring the removal of the appendix to a later date. appendicitis usually recurs with increasing frequency and severity, therefore it is generally agreed that when an attack has subsided it 1s wise to remove the appendix soon, in a quiet interval, in order to prevent the recurrence of a grave or fatal attack. itis, however, a foolish policy to defer operation when an opportunity offers of having it performed early in an attack, for under medical treatment or deferred surgical treatment the mor- tality is about 10%, whereas the risk of early operation is cer- tainly under 0-5 %. see w. h. battle and e. n. corner, she surgery of the diseases of the vermiform appendix (1911). (r. p. r.) apponyi, albert, count (1846- ), hungarian states- man (see 2.226), was from 1906-10 minister of education in the wekerle cabinet. he succeeded kossuth as president of the party of hungarian independence, and advocated universal suffrage. at the outbreak of the world war he adopted the standpoint of a “ truce of god” with regard to all internal dis- sensions. he retired into private life after the outbreak of the revolution of oct. 1918. in 1919 he was elected as a non-party deputy to the national assembly and was head of the hun- garian peace delegation in paris. he became a member of the league of nations union and in 1924 and 1925 represented hungary at the assemblies of the league of nations. iie stands above rather than outside party politics, and his authority as the “grand old man ” of the nation carries unusual moral weight. his published works include recollections of a statesman (1912); “ die rechiliche natur der beziehungen zwischen osterreich und ungarn " in the osterreichische rundschau (vol. 28); in ilungarian: mfy memoirs: 50 years, vol. 1; youth, 25 years in opposition (1922). two volumes of parliamentary speeches have also been published relating to the 25 years’ activity mentioned in the first volume of the memoirs.