When the inflammation is confined to that portion of the cecum that gives attachment to the appendix there may be no pain, or the pain may not be intense, and because of this lack of intensity, the patient tolerates abuse in the line of drugging and feeding until an abscess forms, the walls of which surround the appendix which is inflamed and often gangrenous.  About this time, on account of the gradual increase in swelling, the pressure brings obstruction, partial or complete, causing the symptoms to become suddenly very dangerous; then if vigorous examinations are made to determine the exact status of the disease, don’t be surprised if rupture of the pus sac takes place!  This then demands an immediate operation which if performed will show a gangrenous appendix that had ruptured!  This is quite common and is looked upon as proof positive that an operation was justified; in fact, the proper and only thing to be done, and it should have been done earlier!

This is the opinion of the majority of the profession.  It really appears that surgeons are innocent of the part they play in rupturing unsuspected abscesses and otherwise complicating this disease by much rough handling.

The paroxysmal pain which is characteristic of the early stages of appendicitis may be accompanied by fever, sometimes low and sometimes high, nausea, vomiting and diarrhea.  The vomiting may be severe and there may only be nausea.  If there is much vomiting there will usually not be much diarrhea for the excessive vomiting is an indication that there is obstruction.  In other cases there is both nausea and diarrhea; then the obstruction is either not established, for the trouble is as yet a local inflammation of the mucous membrane, or the diarrhea is from the bowels below the cut-off.

It is safe to prognose obstruction when the vomiting is severe; but if the nausea continues longer than three days, it must be due to eating or to drugs, to taking too much water while there is nausea, or there is more obstruction than can be accounted for by such diseases as suppurative inflammation of the cecum or appendix.

It will be well to remember that diseases of the cecum or appendix or both never cause complete obstruction, except in exceedingly rare cases where adhesive bands are formed, completing the cut-off.  In this connection it will be well to also remember that in absolute obstruction the symptoms of nausea and vomiting, or retching, will continue, while those of appendicitis will stop in three days.  In addition to the continued nausea of complete obstruction, the pulse grows weaker and more frequent and the patient shows great anxiety of expression, there is a sickness that can not be accounted for with a diagnosis of appendicitis or typhlitis, and the patient has the appearance of being desperately sick.  The great pain at the beginning subsides, the temperature falls, the pulse grows rapid and weak, the skin becomes leaky, the mind becomes dull, drowsy and comatose, then a little wandering and death relieves the suffering in a short time.