SYMPTOMATOLOGY 1. Spontaneous pain in appendicitis is often eomplained of by older children as a feeling of heaviness, cramps or needle-like prickings. In other cases a genuine colic appears. The milder forms of periap pendicitis (chronic and somewhat protracted, slowly developed or uleerating) may also oecur after severe attacks of pain; at least the same will be stated by children as being only temporary. in most cases, very severe pain is usually the warning of these attacks, and this: is observed even in smaller children with slight periappenclicular irritation. The severity or mildness of the pain, however, is no measure of the severity of the attaek. The site of the pain is not always the eeeal region but frequently will be located near the stomach. The deep position of the youthful appendix in the pelvis may result in vesieal tenesmus and desire for stool.
2. Pain on pressure [tenderness] always exists in appendicitis, but varies aecor(ling to the intensity of the disease. Periappe»dicitis distinguished by greater sensitiveness of the appencliceal region. The skin is often hyperiesthetic over the appendix. In severe ulcerating: or virulent periappenclieitis, the pressure pain is extremely intense, and the abdominal wall can no longer be pressed. The pressure pain is not always situated over 11.10Burney's point. Because of the position of the appendix in the lesser pelvis, the place of sensitiveness to pressure is frequently- in another spot and is often only established through rectal palpatio». All particulars as regards both kinds of pain in chil dren are to be judged wit') eaution. In severe eases, because of shoek, or early( sepsi.s, diminished tenderness is often present.
3. The tumor (confirmed by palpation and pereussion*) is not. always palpable in appendicitis. Sometimes the appendix ean be palpated only as a small sensitive cord-like swelling; especially is this so in an appendix thickened by ehronie processes. The appendix can be pal pated as an oval or egg-shaped swelling when (Elated by mueus or by pus. The previously mentioned deep position of the appendix in children,
makes a bimanual examination necessary to detect its true condition. It can often be made out as a eord-like buneli in the right pelvic cavity.
Periappenclieitis usually comes with a tumor-like formation whieb, sometimes at first., and usually after one or two clays, is distinctly palpable. But a tumor is seldom clearly defined, as appendicitis is usually a limited inflammation. On the other hand very severe per forative and gangrenous forms do not reveal a circumscribed swelling,, but give symptoms by an extensive board-like rigidity of the right hypogastrium or of the whole lower abdomen. Moreover, the tightly stretched prerectal peritoneal folds are not to be overlooked.
4. Distention and rigidity of the abdominal wall are found in the milder grades of appendicitis, yet the abdomen always remains com pressible. Only in severe cases of pus formation in the lumen of the appendix (empyema) is there found a severe reflex rigidity in the region of the cceum. Periappendieitis is always accompanied by more or less severe distention and reflex rigidity of the abdominal musculature, or it follows surely after the first few hours or in a day, and always after a perforation of the appendix wall. It in creases in undoubted and severe infectious perityphlitis, and in general periappendi eitis reaches its height in the well-known board-like rigidity and distention.
5. Disturbances of bowel movements, mostly consti pation, are found in appendi citis and in periappendieitis, especially at the beginning of the disease. Previous intes tinal catarrhs, which go hand inhand with perforative cases, are often first noted only as a diarrhma. Further and favor able progress is noted by the oncoming of a normal bowel movement; and tile existence or beginning of a diarrhma or more severe eonstipation is looked upon as an advance of the disease process; namely, the charac teristics of a perityphlitic inflammatory condition.