Ernpyeina of time Appendix (Plate 13).—When the pain at Me Burney's point is considerable but still confined to this region, and the temperature and the leucocyte count rise, we have most probably to deal with a purulent process inside the appendix, an empyema, which will either end in perforation or has already perforated. Rectal exami nation, by which we can, even in a child of three years, palpate the abdominal cavity above the navel and can bimanuallv examine the whole ezecal region, will give us valuable information. This is also safer and less painful than deep palpation.
Deep palpation should be carried out in expiration. The examining hand glides deeper with every expiration and we will soon be able, even in refractory children, to reach the iliac fossa and the arteries. Palpa tion of the appendix is always somewhat problematical, as we may be deceived by loops of intestine in that region or by the psoas muscle (the latter we can recognize by motions in the hip-joint). Only when the appendix is very superficial and when it is distended by empyema can we feel it and make a diagnosis with any assurance.
If we operate in this stage, we may save the child from perforation and consequent abscess. We are able thus to remove appendices which are filled to the bursting point. The wound will heal in a few days and the child will t hus lie spared a long period of internal or surgical treatment which would by inevitable after abscesses have formed from perforation.
Peritonitis front Perforation.— Once we can clearly show the exu date, by the dulness and the resistance, per rectum as well as from outside, then we will have to deal with a walled-off purulent peritonitis, and expectant treatment is only permissible when we can prove satis factorily that the symptoms of exudation and inflammation are retro gressive as well as the pain, and that fever, pulse and leucocyte count are going down together. We have known for a long time that even large purulent esudatos may disappear either through the lymph-channels or by going back into the intestine, rarely by perforation into neighbor ing organs, and we may thereby justify our expectant attitude. But when no retrogression is perceptible, or the abscess remains tense shows a tendency to burrow further, or the rectal temperature and the pulse remain high, then we must not wait any longer before we open the abscess.
The operation must be clone most carefully; if we can reach the ap pendix easily we should remove it, but we must never be carried away by our desire to remove the offending organ and in doing this break through the protective wall, as we would then be doing our patient small service. If we cannot reach the appendix easily, then it will be better to wait with its removal until the painless interval, when the process has quieted down. In cases in which it maintains a continued suppura tion it should be removed earlier. The abscess-cavity is emptied, drained and closed (Rein, v. Brunn), and the patient placed in that position in bed in which the pus can run off easily. Our incision must naturally be determined by the location of the abscess. Should Douglas' pouch be filled with pus, then we may advantageously open it through the rectum, after first ascertaining that no intestinal loop is interposed (exploratory puncture with a fine needle (Battle)).
Generalized Peritonitie Sztppuration.—We have described above the treatment of a diffuse peritonitis. Removal of the appendix is here also indicated to close the source of infection.
Chronic F OIMS . —After the first attack has passed without opera tion, leaving only chronic tenderness, frequent exacerbations of pain from distention with gas and from bodily exercise, and when the first attack has been followed by a second one, then it will be absolutely necessary to do an interval-operation "a froid." This is an entirely safe operation which will procure for the patient freedom from his intestinal disturbances.
The postoperative pains from adhesions which are frequently reported in adults have never yet been observed by us in children. The lively peristalsis in children and their innate tendency to get well do not permit so easily pathologic processes which largely depend upon advanc ing age and occupational damages.
For noneperative treatment there will therefore be left the following: I. Those light cases of appendicitis simplex which are difficult to diagnose but which we may treat internally if we only keep the knife in readiness (Sonnenburg), We must, however, beware of mistakes.