fever.

Children troubled with constipation will sometimes be taken with fever and pain in the right iliac fossa and, on examination, a fullness will be found; the sensitiveness will not be so great but that an examination can be made and a sausage shaped tumor may be outlined; of course, the disease will be named appendicitis and this is enough to scare a whole neighborhood, and the child will be carted off to a hospital and operated upon for appendicitis.

If the child is left alone, given no food, and ice put on the sensitive parts if the temperature is 103 degree F., or hot applications if the temperature is less, the tenderness will probably go away in two or three days; if it does not, an abscess will form and empty into the cecum. If the child is fed, and the tumor manipulated—subjected to unnecessary examinations—the abscess may be made to burrow down toward the groin, which should be avoided for it is a very undesirable complication. The first abscess is typhlitic, the second is perityphlitic. The first may form without the aid of bruising in the manipulation of repeated examinations, but the second must be forced by bad management. The latter abscess, I have reason to believe, is the former abscess driven, by repeated manipulations, to burrow downwards instead of opening into the cocum.

Fecal abscess, arising from ulceration of the colon, may be mistaken for appendicitis. There is a localized swelling, immovable in breathing or when pressed upon, and having a tympanitic sound on percussion over it with dull sound on pressure and heavy stroke.

The symptoms of appendicitis are: Pain in the front, lower, right side of the abdomen. It is paroxysmal and caused in the main by peristalsis—the regular action characteristic of the sewer function of the bowels, which is for the purpose of forcing the contents of the intestines onward to the outlet, and which ordinarily is carried on without pain; but, in bowel obstructions of any kind, the onward flow of the bowel contents is cut off resulting in great pain where there is much irritability, for irritation of any kind always increases this expulsive movement. Food, taken in health, stimulates this contraction and if taken when there is inflammation—enteritis, colitis or inflammation of any part—the contraction is increased and necessarily painful. Think of the pain that the subject of diarrhea has, then imagine what that pain must be if there should be obstruction so that the fecal matter could not pass. That is as near as I can describe what the pain of appendicitis is. Anything that will stimulate these contractions will throw the patient into great distress. Food or drugs will cause pain, and water, the first few days of the illness, will do the same.

In inflammation of the cecum, where the inflammatory process remains local and there is no obstruction more than constipation will make, the patient will be troubled with occasional attacks of pain which will pass as colic; or there may be a diarrhea, lasting for a day, every few weeks or months with constipation between the attacks. These cases may lead in time to ulceration, then to fecal abscesses and they are often diagnosed chronic appendicitis.

When the inflammation is confined to that portion of the cecum that gives attachment to the appendix there may be no pain, or the pain may not be intense, and because of this lack of intensity, the patient tolerates abuse in the line of drugging and feeding until an abscess forms, the walls of which surround the appendix which is inflamed and often gangrenous. About this time, on account of the gradual increase in swelling, the pressure brings obstruction, partial or complete, causing the symptoms to become suddenly very dangerous; then if vigorous examinations are made to determine the exact status of the disease, don't be surprised if rupture of the pus sac takes place! This then demands an immediate operation which if performed will show a gangrenous appendix that had ruptured! This is quite common and is looked upon as proof positive that an operation was justified; in fact, the proper and only thing to be done, and it should have been done earlier!

This is the opinion of the majority of the profession. It really appears that surgeons are innocent of the part they play in rupturing unsuspected abscesses and otherwise complicating this disease by much rough handling.

The paroxysmal pain which is characteristic of the early stages of appendicitis may be accompanied by fever, sometimes low and sometimes high, nausea, vomiting and diarrhea. The vomiting may be severe and there may only be nausea. If there is much vomiting there will usually not be much diarrhea for the excessive vomiting is an indication that there is obstruction. In other cases there is both nausea and diarrhea; then the obstruction is either not established, for the trouble is as yet a local inflammation of the mucous membrane, or the diarrhea is from the bowels below the cut-off.

It is safe to prognose obstruction when the vomiting is severe; but if the nausea continues longer than three days, it must be due to eating or to drugs, to taking too much water while there is nausea, or there is more obstruction than can be accounted for by such diseases as suppurative inflammation of the cecum or appendix.

It will be well to remember that diseases of the cecum or appendix or both never cause complete obstruction, except in exceedingly rare cases where adhesive bands are formed, completing the cut-off. In this connection it will be well to also remember that in absolute obstruction the symptoms of nausea and vomiting, or retching, will continue, while those of appendicitis will stop in three days. In addition to the continued nausea of complete obstruction, the pulse grows weaker and more frequent and the patient shows great anxiety of expression, there is a sickness that can not be accounted for with a diagnosis of appendicitis or typhlitis, and the patient has the appearance of being desperately sick. The great pain at the beginning subsides, the temperature falls, the pulse grows rapid and weak, the skin becomes leaky, the mind becomes dull, drowsy and comatose, then a little wandering and death relieves the suffering in a short time.

These symptoms are of collapse and they may come on in the course of a typhoid fever, or other diseases of the alimentary canal; they always mean a fatal toxemia either from obstruction or perforation, and occasionally the only forerunning symptom is sudden abdominal pain. Circumstances must guide in making a diagnosis. If, during a run of typhoid fever, there should be sudden abdominal pain followed with symptoms of collapse and nothing to account for it, it means perforation; an immediate operation may save the patient; nothing else will.

A sudden pain in the abdomen of a woman during menstrual life, with positively no unusual menstrual symptoms and no trouble in the right ileo-cecal region, indicates perforation of the stomach or of the gall-bladder. If there have been a menstrual period or two gone over with a slight showing, and some uneasiness, perhaps nausea, perhaps a flow with pain somewhat simulating abortion, a sharp, severe abdominal pain followed with quickening of the pulse and an exceedingly anxious facial expression, ectopic pregnancy with rupture of the tube may be suspected. One must also keep in mind renal calculus in determining bowel diseases.

Authors pretty generally unite in declaring that appendicitis is a dangerous disease. In his late book, "The Abdominal and Pelvic Brain," Dr. Byron Robinson of Chicago says, "Appendicitis is the most dangerous and treacherous of abdominal diseases—dangerous because it kills and treacherous because its capricious course can not be prognosed. . . . For years I have made it a rule to recommend appendectomy to patients having experienced two attacks. Fifty per