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ETIOLOGY. In Order Vpxl considering the etiology in children, the pre- disposing factors play an important role: i. Ap- pendicitis in children is not infrequently associated with other infectious diseases : Influenza, measles, acute rheumatism, enterocolitis, typhoid, and tonsil- 502 BOWER: APPENDICITIS IN CHILDREN. [New York Medical Journal. litis. It is the opinion of many that the excess of lymphoid tissue together with a thinning of the submucous coat accounts for the frequency of asso- ciated appendicular inflammation in these cases. 2. Abdominal injury predisposes to appendiceal in- flammation in the young adult, 2.5 per cent, of cases giving such a history. 3. Fecal concretions are usually Purchase Vpxl larger and are more frequently found in early life. 4. Intestinal Buy Cheap Vpxl parasites are uncommon but are more frequently associated with appendicitis in juveniles. 5. Foreign bodies are more frequently found in appendices in children than in adults. We have seen lemon and grape seeds, toothbrush bristles, toothpicks, and, within the past month a common pin. In this instance the patient, two and a half years of age, entered the hospital with a his- tory of lower abdominal pain, nausea, vomiting, and frequent urination, of four days' duration. At op- eration we found a localized abscess with a rusty pin well down in Buy Vpxl the pelvis. The tip of the appendix was markedly hypertrophied, the pin undoubtedly having lodged in this portion of the organ for some time prior to its passage into the peritoneal cavity. The direct causative factors are the bacillus coli, staphylococcus, streptococcus, bacillus pyocyaneus, and the tubercle bacillus. This is the order of fre- quency with which the above mentioned germs at- tack the appendix. It must be remembered, how- ever, that tuberculosis of the appendix in adults is invariably secondary to a pulmonary lesion, while in young adults it usually follows or accompanies a general abdominal tuberculosis. SYMPTOMS. The symptoms of appendicitis in children are the same as the symptoms in adults, the sequence being pain, nausea and vomiting, localized tenderness, rigidity, temperature, leucocytosis, and at times uri- nary frequency. The initial symptom of pain is of a variable quality in children. As a rule general abdominal, primarily ; later, in the majority of cases, localized in the right lower quadrant. Ow'ng to the relatively greater length of the appendix in children, a certain percentage complain of right hyjiochondriac. or left iliac pain, which renders a correct diagnosis rather difficult at times. Vomit- ing is more variable in appendiceal inflammation in children, due to the fact that children are more liable to gastrointestinal disturbance than the adult. In a fair percentage of Cheap Vpxl cases the history shows that nausea and vomiting preceded the usual initial symptom pain, but after careful investigation it is found that in the greater percentage of cases nausea and vomiting followed the initial symptom. The severity of the nausea and vomiting depends upon the causative germ. In streptococcus infection the most severe vomiting occurs, less in staphylococcic, and least in colon and tubercle infections. The usual history is that there are one or two attempts at vomiting which subside and do not recur unless the peritoneum is involved. When this takes place the vomiting recurs and is more persistent, the vomitus consisting of the contents of the Order Vpxl Online upper intestinal tract above the site of inflammation. Localized tenderness Vpxl Online before the involvement of the parietal peritoneum is not constant. It must be remembered that the appendix in children is more liable to vary in position, so that we frequently en- counter cases where, because of a post cecal posi- tion, or one low in the pelvis, we have very little abdominal rigidity. When, however, the parietal peritoneum becomes involved, the abdomen becomes rigid and distended. Temperature in children is more variable than in adults, and inasmuch as the colon bacillus is the most frequent offender, the tem- perature is usually of moderate degree ; the staphylo- coccus producing a higher range, and the strepto- coccus the maximum degree of temj>erature, in these cases a sudden drop being indicative of perforation or gangrene. I would Purchase Vpxl Online call attention to the fact that one may have a tubercular involvement Buy Vpxl Online of the cecum and appendix with little or no temperature, Generic Vpxl perhaps only an afternoon rise to 99-3°, or an en-

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