Typhoid fever, ileus and perityphlitic abscesses of the burrowing form must be considered in the differential diagnosis. Exclusive frorn the course., the history and the lencocytosis we should consider the stools, temperature curve and the \Vidal reaction in the differential diagnosis from typhoid fever. The presence of a perityphilitic tumor and examination of the hernial opening helps in a differential diagnosis with liens. An examination of the vertebral column will exclude the presence of a psoas abscess.
course is extremely variable. Surprises in this disease should not be unexpect(al. Even apparently favorable forms of appendicitis, as well as periappendieltis, often take on an unlooked for and grave course. In appendicitis, as well as in simple periappendieitis, the usual appearance after several (lays is as follows: The tumor becomes smaller and after a few days, or weeks the pain on pressure and the sensitiveness disappear and complete recovery sets in. In other cases chronic granulating processes remain, in still others, retention of secretion in the lumen of the appendix and sometimes, torsion of the appendix occurs.
On careful examination the painful and thickened appendix can always be palpated. One attack can naturally lead to further attacks.
The second group of cases leads to suppuration ill the. surrounding tissue. (1) The pus formation can resolve itself, as the state of scybalous masses in old cicatrices proves. (2) In many cases a recrudescence of the symptoms occurs in the first few clays, the inflammatory tumor increases in size with more pain. This can slowly heal spontaneously or become smaller or disappear more or less quickly, or burrow and become long drawn out, with fever. Even then resorption is yet possible when death from septimemia does not follow. (3) The abscess may per forate into the intestine, the bladder, or externally. (4) The case may pass quickly into a general typhlitic condition. All these conditions may arise when the appendix has not been wisely extirpated in the beginning. In mo.st favorable cases spontaneous healing leaves behind cicatrices, kinles, and even small absce.sses which can cause further recurring relapses.
The third form of perityphlitis is even worse. The severe general symptoms with which this starts in are not relieved or seen to pass by; then immediately after the shock there ensues the appearance of a general septic inflammation. The local symptoms are exceptionally severe. The deeper situated abdominal pockets are filled with exuda tive masses, etc. Often a general peritonitis follows quickly or there are metastatic abscesses in the chest, phlebitis of the mesenteric veins, etc., and in a. few clays the child (lies from septic symptoms, if a present or quickly developing peritonitis does not give a chance for life or the operative procedure does not come early enough.
Combinations of all these forms naturally occur. In by far the
largest number of cases it resolves itself in children into either an appendicitis or a small periappendicitis of a mild course and with spon taneous cure; or an unfavorable course with insidious and severe puru lent or putrid typhlitis. About SO per cent. of all perityphiltic eases heal spontaneously, without recurrence, according to I-launder and Sahli. The smaller number of cases in children is in accord with this percentage for grown people. Unfortunately in the statistics of the surgeon only the severe cases clinically treated are noted, not those of private practice, so that an unprejudiced person often gets a false picture. Again, the severe pus forms, when suitably and rightly treated, make good recoveries, with a quick and correct operation.
prophylaxis in children is very valuable not only in the prevention of the disease, but in the avoidance of a recurrence. Evidences of digestive disturbances of all sorts, including parasites should be attended to. Careful feeding according to the age and the digestive power and regularity in bowel movement is necessary. Timely attention to the ever present digestive disturbances, especially constipation and diarrhma, quiet and protection as soon as the least pain conies on are among the curative measures designed to ward off appendicitis and to arrest the involvement of the peritoneum.
Therapeutics.—No firm or unbreakable rule of treatment can be laid down for the treatment of appendicitis and periappendicitis. Here, as in no other disease, is it necessary to individualize. The radical surgical element advise an unconditional early operation, and the extirpation of even slightly diseased appendices so as to off.set, most optimistically, the unfortunate results of the severe symptoms in the first few (lays, and in the hope of spontaneous healing. The expectant treatment is important. We cannot foresee the course of the disease in the first few (lays. Absolute quiet, the cessation of feeding, or small sips of lee or weak tea in the milder forms (each quarter hour a teaspoonful) and the ice pack, not too heavy, fastened on a. hoop stretcher, for use at night. Damp, warm compresses for the first few days are allowed as a general procedure for those who cannot. endure the ice. Relative to the medi cal treatment, the views are widely divergent; for instance the surgical element discard the use of opium because it clouds our knowledge of the disease by placing the intestines at rest. The subcutaneous injec tion of morphine is recommended by some. Opium and morphine are given to children in the usual closes: tincture of opium, five times daily, one to eight drops, according to age and necessity; morphine is given with greater care, beginning with a dosage of 0.001 Gm. (,4, gr.). In general ophun should be discarded.