The diagnosis of the condition is not always easy, particularly when it is the first attack. Broca has shown that there are cases of appendicitis which are accompanied with attacks of continuous vomit ing, and in which the removal of the appendix brings about permanent cure. The uselessness of dietetic and mechanical methods of treatment (irrigation of the stomach and intestine), also speak against thc gastro intestinal origin of the disease. The differential diagnosis, too, from tuberculous meningitis, is often difficult. However, thc sudden onset, the continuation of vomiting, the lack of arrhythmic pulse and the re tention of consciousness suggest recurrent vomiting. Moreover, the characteristic odor of the breath, and the large acetone content of the urine are valuable in this regard. Notwithstanding, the question can be very complicated, since, as in cases reported by Richarcliere and by Malian, real cyclic vomiting and appendicitis may exist together, and the appendectomy, although it cures the latter, has no effect upon the former condition. In other cases, paroxysmal pains, the evidence of a mass at the characteristic point, or increased resistance of the muscles at the right side of the abdomen, and sensations in the neighborhood of MacBurney's point, are in favor of disease in the appendix. The diagnosis is easy in subsequent attacks.
The prognosis of the disease is generally very favorable; still there are in the literature several fatal cases (cited by Northrup), which warn one to have a certain reserve. On autopsy, the internal organs were found normal; only in two cases was there hypertrophy of the epithelium of the whole intestinal tract (?) and a slight degener ation of the glomeruli, findings much in need of verification.
The treatment should, in the first place, curtail the attack as much as possible, and, secondly, prevent its return. The most diverse methods
have been used and poor results obtained. In accordance with the existing hypothesis, treatment with alkalies has been attempted (Kdsall, Pierson and others); that is the administration of sodium bicarbonate or acid sodium phosphate in large (loses up to 24 Gm. (360 gr.) in 24 hours, although it is not altogether clear to me how such quantities can be retained by a child which vomits every drop of fluid.* Moreover, the result obtained by me in two cases, by the means of citric acid, speaks against the necessity of large doses of alkali, from which also other authors (Griffith) saw no particular improvement.
Complete abstinence from food is obviously necessary. When the vomiting begins to abate, Malian advises the administration of ice colcl sugar solution in order to make use of the curative effect of the carbohydrate. If the los.s of fluid is great, and the appearance of the child is alarming, energetic measures are indicated, and one resorts to injection of physiological salt solution per reettun or to subcutaneous infusion in quantities of 40-60 c.c. (1-2 oz.) once or twice daily.
In the interval, the diet Mlould be sensible and easily digestible, the stools regular, and mental and physical overexertion carefully avoided. Whether rendering the reaction of the urine neutral as recom mended by Edsall, who administers for this purpose fixed alkalies, or the mixture suggested by Malian [aqua destill. 1000 c.c. (1 quart) sod. sulph. 10 Gni. (21 dr.), sod. phosph. 5 Gm. (IA dr.), sod. biearb. 5 Gm (1/ dr.), sod. brom. 3 Gm. (45 gr.), a wine-glass of this before meals until the bottle is emptied, beginning every month] really prevents the onset of a new attack must be learned by further experience.