144 The Philippine Journal of Science i9i8 



number no special mention was made of any marked abdominal 

 discomfort. The initial pain due to obstruction and distension 

 of the lumen of the appendix is often agonizing, although all 

 grades occur. While this pain is present, the disease is confined 

 to the appendix, and this severe pain is usually transient, reach- 

 ing its height within four hours from the onset and at that time 

 generally localized in the appendix region. Probably 75 per cent 

 of the cases subside at this point — a few in thirty-six hours. 

 If there is a sudden cessation of the pain, this is a danger signal 

 indicating perforation. 



We have found the temperature of recently admitted patients to 

 be of comparatively little diagnostic value, as it is well known 

 that the excitement dependent upon change of scene, often irreg- 

 ular transportation, and admission to a hospital will result in a 

 much lower temperature than the patient exhibited before being 

 brought to the institution. 



Of the reflex gastrointestinal symptoms, nausea, unaccompa- 

 nied by actual vomiting, was present in 9 instances, vomiting 

 in 18, constipation in 9, and diarrhoea in but 3 of the series, no 

 disturbance being recorded in the remainder of the cases. 



The nausea and vomiting follow the initial pain in the acute 

 cases and are reflex, the nervous mechanism of the appendix 

 being connected with that of the stomach and small intestine. 

 The primary nausea usually subsides fairly promptly. 



On examination, tenderness in the region of appendix is prac- 

 tically always present in acute attacks. It is hard to elicit in 

 the very stout and the very nervous. More or less rigidity of 

 the abdominal wall in the lower right quadrant is present, al- 

 though a careful comparison with the left side is needed in 

 many instances to make this point apparent. Tenderness and 

 rigidity in parts removed from the appendix region are encount- 

 ered at times and may prove misleading. Four of our cases 

 showed generalized abdominal tenderness, and 1 a marked area 

 sensitive to palpation confined entirely to the left hypogastric 

 region. Eight complained of no special tenderness, the others 

 of soreness higher up than the classical point and often far 

 toward the posterior portion of the body. Exploration of the 

 rectum is often of great importance. 



In this clinic where we have come to the point of immediate 

 operation, in every case of acute appendicitis, little stress is now 

 laid on the leucocytic content of the blood in the frank cases. 

 It is in those cases where some doubt exists as to the exact 

 nature of the condition that we depend more upon the result of 



