APPENDICITIS
IN CHILDHOOD
A
Study
of
1,358
Cases
By Luther A. Longino, M.D., Thomas M. Holder, M.D., and Robert E. Gross, M.D. Surgical Service of tileChildren’s Hospital, and the Department of Surgery, Harvard Medical School
Accurate early diagnosis is the most
im-p()rtant single factor in the care of the
patient with appendicitis. The triad of
ab-dominal pain, fever and vomiting should be considered indicative of appendicitis
un-til proven otherwise. Boys are affected
slightly more frequently than girls. In the present series, there were 743 boys, 56% of the total group. Appendicitis is rare during
the first year of life, uncommon during the
second year, but after this is seen with
rap-idly increasing frequency.
In older children, symptoms follow the
more classical course of pen-umbilical pain
followed by nausea, vomiting, low-grade
fever and, in a few hours, shift of the pain
to the right lower quadrant. In smaller chil-dren, vomiting is apt to occur before the
parents are aware of any abdominal dis-comfort. Children are generally vague and
(Accepted March 4, 1958; submitted February 10.)
ADDRESS: (L.A.L.) 300 Longwood Avenue, Boston 15, Massachusetts.
ARTICLES
238
PEDIATRICS, August 1958
PPENDICITIS in the pediatric age group is still of paramount importance
be-cause of its frequency. It is the most com-mon condition requiring intra-abdominal
surgery in infancy and childhood. During the past few decades the mortality and
mor-l)i(lity from this disease have shown a
con-stant decline. At the present time the mor-tality from appendicitis should be and is, in
the better institutions, practically nil. It is
the purpose of this paper to present the re-suIts of the experience at Boston Children’s
Hospital with all the proven cases of acute
appendicitis treated on the Surgical Service between July 1, 1944, and January 1, 1957.
There was a total of 1,358 cases.
DIAGNOSIS
inaccurate in describing the location of pain
and it is frequently impossible to obtain a
history of early pen-umbilical discomfort.
Pain is usually constant, due to the
inflam-matory process in the appendix but may be
colicky, due to obstruction of the
appendi-ceal lumen.
Vomiting is present in almost all cases
and is usually preceded by anorexia of
vary-ing degree. Vomiting may have occurred
only once but if symptoms are of long
dura-tion, it is apt to have been persistent.
Younger children seem to vomit more
re-peatedly than those of the older age group.
Fever is usually low-grade in the range
of 37.8 to 38.3#{176}C but if rupture has
oc-curred and peritonitis ensued, the
tempera-perature is
likely
to be 39.4#{176}Cor more.Bowel movements may be normal
al-though constipation is more common;
diar-rhea can occur when an inflamed appendix
is adjacent to the sigmoid, terminal ileum
or when early peritonitis is present. Urinary
symptoms are uncommon but may be
asso-ciated with an acutely inflamed appendix
lying in the region of the right ureter or
bladder.
Only a small percentage of children with
appendicitis have a history of previous
at-tacks of abdominal pain. When previous
similar attacks have occurred, an
appendo-fecalith is apt to be found. Other illness
pre-ceding acute appendicitis is not common,
though history of recent respiratory
infec-tion is not rare in any group of children.
Since the history frequently gives only
a hint to the diagnosis of appendicitis, much
ARTICLES 2:39
findings. The symptoms, especially in the
small child, are frequently very nonspecific -irritability, fretfulness, fever, loss of appe-tite, and vomiting. This sort of history may
be given by the parents who have a small
child with an infectious process almost any-where in the body. The history is mostly second-hand by way of the parents whose observations are flavored by their
interpre-tation of what a particular behavior means
in their child. The statements of the chil-dren themselves are frequently vague and they have difficulty in expressing their ex-act feelings and the location of the pain.
For these reasons a very careful and
thor-otigh physical examination is imperative.
Time spent in gaining the co-operation
of the child is well worthwhile. The exam-ination of the abdomen of a crying, kicking
child is not only impractical but the findings
are utterly worthless. While one is trying to gain the child’s confidence, much informa-ti()n can be obtained by observation. The extent of dryness of the skin, the position of the legs, the type of respiration, the luster
of the eyes or the extent to which they are
sunken, and the reaction to those about him
may give one a good idea as to just how sick the patient is and may give a hint of the site of the pathologic process.
If the child isresting quietly in the par-ent’s arms, it is a good practice to palpate
the abdomen gently before moving him.
Merely leaving the parent’s arms is fre-quently enough to upset a child for some
time. The abdomen should be palpated
gently with warm hands, starting on the por-tion of the abdomen which is least likely to
be tender, then progressing to the area
which is most likely to be tender.
Tender-ness is the most constant single finding in appendicitis and is almost inevitably
pres-ent. The tenderness is usually maximum in the right lower quadrant, but may be most
intense in the right upper quadrant or left
lower quadrant. The appendix in the child
is longer in relation to the size of the ab-dominal cavity than in adults and hence
may present maximum tenderness over a
comparatively larger area. Muscle spasm
is the second most common finding. This is best detected by simply resting one’s hand
on the abdomen and noting after a few
mo-ments whether there is relaxation of the abdominal musculature during inspiration.
In simple appendicitis, the findings are
usu-ally localized, while in ruptured
appendi-citis the findings are more diffuse. Bowel sounds are, as a rule, hypo-active but in the case of a spreading peritonitis may be by-peractive. When an appendiceal abscess is present, it may be palpated abdominally but
is more often detected on rectal
examina-tion.
There are a small number of sick children
who, in spite of almost infinite patience on
the part of the examiner, are too irritable to be adequately examined. In this group of children, usually the 2- to 4-year-olds, it is most helpful to administer a barbiturate
rectally. We prefer pentobarbital using a
dosage of 5.5 mg/kg of body weight
dis-solved in 10 ml of isotonic saline and given
via a small rectal catheter. This dosage is
safe and usually produces sound sleep in 30
to 45 minutes. The child can then be
exam-ined without difficulty. The parents are also
much happier since the child is sleeping
quietly and is in no obvious discomfort.
The physical findings are not masked by
this medication. Muscle spasm persists but
voluntary guarding is absent. When a
tender area is palpated, the child will arouse
momentarily from sleep and then drop back
into slumber after the examining hand is
removed. Under these conditions, the
find-ings are much more valid than in an
irrit-able, crying child. (An opiate is, of course,
never used for this purpose.)
After the abdominal examination, a
com-plete physical examination must he done to
rule out the many other conditions which
may produce abdominal pain in children.
The physical examination is concluded with
a digital examination of the rectum. Positive
findings are present by rectal examination
in abollt three-fourths of the cases of
ap-pendicitis. Tenderness may be more
ac-curately localized and induration may
240
process. A firm, tender mass indicates the
presence of an abscess, while a diffuse,
boggy
tenderness is found in the presence of generalized pelvic peritonitis.The usual laboratory data which are
ob-tamed are a complete blood count and a
routine urinalysis. The leukocyte count is
usually elevated to about 15,000/mm’, while
counts of 20,000/rnm or more are more
a1)t to imply the presence of a ruptured
ap-pendix. Elevation of the polymorphonuclear
ratio is a more constant finding. Anemia may l)e present in children who have been sick for some time and especially in those who
have had an appendiceal abscess of several (lays duration.
The urinalysis helps to exclude
ab-dominal pain of urinary tract origin.
Ace-tonuria or its absence is helpful in
determin-ing the metabolic response to infection.
Children with acetone in tile urine have
sufficient alteration in metabolic activity that
they tolerate anesthesia and operative
pro-ce(lures poorly. With adequate hydration
and reduction of fever, acetone is no longer
Present in tile urine.
There are a number of conditions which
at times may cause a patient to have
symp-toms and physical findings resembling
ap-pen(licitis. If tile diagnosis is not apparent
after the initial examination, a few hours of
observation is usually helpful in establishing
the diagnosis. If the physician can see the
patient frequently at home, this is perfectly adequate. \Ve have usually found it more
satisfactory to admit such patients to the
hospital where they can be seen frequently
and, if necessary, the blood counts can be
repeated. If appendicitis is actually present,
little or no harm will he done by this period
of observation. When the symptoms are not
due to appendicitis, it usually becomes
ap-parent during this time and many needless operations can be avoided. If a reasonable
doubt still persists about the possibility of
appendicitis, a laparotomy should be
under-taken.
TREATMENT
The treatment for appendicitis is prompt
appendectomy. To operate on these children
with safety, they must be in the best
condi-tion the disease process permits.
Preopera-tive preparation of patients with simple
ap-pendicitis, with symptoms of short duration
and without rupture, usually presents no
problem. The medication consists of
pento-barbital, morphine and atropine, in
appro-priate dosages. An intravenous infusion is
started, and the stomach is decompressed
through an indwelling nasogastric tube.
For those children with symptoms of
longer duration and those who are toxic from ruptured appendicitis with peritonitis,
the preoperative period of preparation is of
the utmost importance. They are usually
dehydrated, ketotic, and have rapid pulse
and high fever. Children in this condition
tolerate anesthesia and operative procedures
very poorly. We prefer to have the pulse and
temperature on the decline at the time of
operation, with the pulse less than 120/mm
and the rectal temperature 38.7#{176}Cor less.
These are rather arbitrary figures but
expe-rience has shown that if these criteria are
met, the patients tend to tolerate the
opera-tive procedures satisfactorily.
Preoperative preparation in these sick
children includes hydration, sedation,
re-duction of fever, and the use of antibiotics.
An intravenous infusion is started at once to
combat the dehydration and replace the
electrolyte loss due to vomiting. If the child
is very ill, or is anemic, he is given plasma
or blood. Sedation in the form of
pento-barbital rectally and morphine
subcutan-eously are used liberally to relieve pain,
de-crease restlessness and allay apprehension.
Acetylsalicylic acid is given every 3 to 4
hours per rectum in appropriate dosages.
Hydration of course enhances the reduction
of fever but the lowering of the temperature
can also be facilitated by tepid water
sponges, the use of electric fans, and, on
occasions, by placing the patient in an iced
oxygen tent. The stomach is decompressed
with a nasogastric tube connected to
inter-mittent suction. The child is placed in
Fowler’s position to allow better respiratory
exchange and to allow any purulent
ab-ARTICLES 241
(lomen. Atropine is withheld until the time
of operation when it is given intravenously.
This drug is withheld because, in those
pa-tients who have been atropinized, it is
im-possible to tell if the failure of the
tempera-ture and the pulse to respond to therapy
is due to the atropine or due to the
underly-ing infectious process.
Antibiotics are administered
preopera-tively to children who are thought to have
ruptured appendices. Penicillin and
strepto-mycin are given intramuscularly. In
addi-tion, the very ill children are usually given
()I1C of the broad-spectrum antibiotics or
sodium sulfadiazine intravenously.
As soon as the patient is hydrated, the
urine no longer contains acetone, and the
pulse and temperature are down to
accep-table levels, tile patient is operated on. This
preparation can usually be accomplished in
a few hours; it rarely takes longer than 6
or 8 hours. We never wait for the infectious
process to be walled-off before operating.
Tile program of “Ochsnerization” no doubt
has a place in the treatment of adults with
appendicitis, but in children and infants
this approach is unwarranted. These small
subjects do not wall off the ruptured
ap-pendix as vell as adults, who have a longer,
more effective omentum; hence, children
tolerate continued peritoneal soiling poorly.
The delayed approach causes an increased
morbidity, longer hospitalization, increased
expense, and no better results than those
with prompt appendectomy.
The anesthetic of choice is open-drop
ether. Since almost all of these children are
receiving intravenous infusions when they
get to the operating room, anesthesia is
usually induced with pentothal sodium.
This method of induction is quite
satisfac-tory for both patient and anesthesiologist,
hut is seldom practical for children less than
3 years of age. In the very ill child,
cyclo-propane is usually administered.
A McBurney incision is usually employed.
If tile diagnosis is in doubt and there is a
possibility of an extensive procedure being
necessary’, a right rectus incision with lateral
retraction of the rectus muscle is made.
Because of the slightly higher position of
the cecum in a small child, the incision is
made somewhat higher in the small subject
than in the adult. The McBurney incision
was used 1,224 times (90%).
The actual removal of the appendix
usti-ally presents no special problem. After the
mesoappendix has been divided, the base
of the appendix is ligated with a catgut
ligature and the appendix excised. The
stump is treated with phenol and alcohol
and inverted with a silk purse-string
su-ture. If, however, the cecal caput is
in-flamed and edematous, it is useless to
at-tempt an inversion of the stump. When the
omentum is adherent to the appendix, the
adherent portion is removed with the
speci-men. Should the omentum be dissected
from the appendix, there is a good
possibil-ity that a gangrenous or ruptured appendix
would be exposed and the operative field
contaminated.
In the early years of this series, no special
effort was made to remove the appendix
when an appendiceal abscess was drained.
More recently, we have tried to remove tile
appendix whenever possible and, indeed,
are generally able to do so. If the appendix
can be removed during the primary
pro-cedure, the morbidity is reduced and the
necessity of a secondary procedure to
re-move the appendix is obviated.
We have employed drainage in all cases
of ruptured appendix. Although it is
obvi-ously impossible to drain the general
ab-dominal cavity for more than a day or two,
we have the distinct impression that a
num-ber of these children do much better when
the abdominal cavity is drained than they
would have done had drainage not been
used. There is usually a moderate amount
of purulent drainage in the first few clays
postoperatively. This represents pus which
would have had to be absorbed by the
pen-toneal cavity if external drainage had not
been provided. Whenever a pelvic or
ab-dominal abscess does develop, it is more
apt to rupture into the drain tract and
evac-uate itself through the wound. A
APPENDICITIS
lateral gutter into the pelvis and brought
out through the wound. Care is taken to
avoid placing tile drain adjacent to the
ap-pendiceal stump for fear of contributing to
the formation of a fecal fistula.
The high incidence of appendofecalith
associated with ruptured appendix (66% in
Scott and Ware’s2 series) make it worthwhile
(if a fecahith is not found within a ruptured,
excised appendix) to make a cursory
ex-plonation of the right lower quadrant in
search of a free fecalith. It is possible to find
and remove the fecalith from the free
pen-toneal cavity in a surprisingly large number
of cases and thereby decrease the incidence of P5t0I)erative ai)scesS formation.
We have never placed antibiotics or
anti-Inicroi)ial drugs directly into the abdominal
cavity. We ilave always maintained that it
is far better to have the patient saturated
with such substances (by parenteral
admni-stration) i)efore he gets to the operating
table.
The postoperative care of a patient with
acute unruptured appendicitis is usually
rather simple. In most instances the Levine
tube is removed the clay following
opera-tion and the child is given clear liquids by
moutil. Tolerating this well, the diet is
gradually increased and he is given a full diet and allowed to be up and around the ward in 3 or 4 days. Tile average hospital
stay is about 5 to 6 days. As a rule,
anti-biotics are not employed in simple
appendi-citis.
The postoperative care of patients with
ruptured appendicitis is much more
vigor-ous than with the previous group. The
chld is placed in Fowler’s position
postop-eratively in an effort to drain any penitoneal
fluid into the pelvis. If this is done, any
abscess which forms is more likely to form
in the pelvis than in a more dangerous
sub-pilrenic and subhepatic area. The
gastro-intestinal tract is kept at rest for some days
by maintaining nasogastnic suction until
peristaltic activity is resumed. During this
period of time, appropriate fluids are
ad-ministered parenterally in adeqtiate
quanti-ties to relieve dehydration and to minimize
any serious electrolyte disturbances.
Seda-tion is used freely, usually in the form of
morphine given at regular intervals for 2
or 3 days. This gives these sick children
with a tube in the nose and a needle in the
arm much needed rest and freedom from
pain. Acetylsalicylic acid is given rectally
for appreciable elevations of temperature.
Antibiotics are given routinely, penicillin
and streptomycin usually being employed
for a period of about 5 days. By this time
the patient is usually taking feedings orally
and can be given medications orally.
Sul-fadiazine is an excellent agent for use in
peritonitis of appendiceal origin and has
been used in most of the cases of ruptured
appendicitis in this series. During the past
few years, the broad-spectrum antibiotics
have been used with greater frequency as
oral medications. Very sick patients are
given protein parenterally in the form of
blood, plasma, or human serum albumin.
Widespread peritonitis rapidly depletes the
body’s protein reserve before it is manifest
by a significant drop in concentrations of
hemoglobin or protein in the blood. The
abdominal drain is usually shortened daily
beginning about the second postoperative
day. This of course varies somewhat
de-pending on the amount of drainage, but
generally the drain is completely removed
by the fifth to seventh postoperative day.
Rectal examinations are done every day or
two to follow the course of development of
any rectal mass and to detect the presence
of pelvic abscess should one occur.
The patient who has had a ruptured
ap-pendix is hospitalized until there has been
no fever for at least 2 or 3 days, the
leuko-cyte count is returning to normal, there is
no evidence of abscess on rectal
examina-tion, no significant drainage from the wound
and the drainage tract has been healed to
the extent that it cannot be probed below
the fascia of the abdominal wall. On the
average this takes about 12 days. It is well
to give sulfadiazine or a broad-spectrum
antibiotic for several days after leaving the
hospital. After discharge from the hospital,
TABLE I
RELATION BETWEEN TYPE OF API’ENnIcITIS ANt) AGE
Age Acute Acute Ruptured
(years) Unruptured Ruptured (%)
0-I 1 .5 83
I- (; 4J* H7
-4 .58 17.5 73
4-6 I1 148 57
6-I2 478 t3I 33
1s-18 84 11 I
18 antI over 8 0 0
Total 747 611 45
are ;tsVml)tOnlatic, receiving no niedication,
dll(1 ulltil any’ I)elvic niass (which sonic have
had) has completely disappeared.
ANALYSIS
OF CASE RECORDS
Tile Present series includes all patients
seen Oil the Surgical Service of Boston Children’s Hospital with acute appendicitis
l)etVeeIl July 1, 1944, and January 1, 1957. This supplements earlier reports of series from this institution by Hudson and
Cham-berlain’ and by Scott and Ware.2 During
this period of time, there were 1,358 cases
of proven acute appendicitis. In almost all
instances tile appendix was examined
his-tologicallv and, in these cases, the histologic diagnosis was used. There are a few cases
ill wilich the appendix was not examined llistologicalh’ and in these cases the
diagno-sis of the operating surgeon was accepted. Those patients who were thought to have
possible appendicitis prior to operation but
proved at time of surgery not to have acute
appendicitis were not included in this series. There was one death in this series of 1,358
patients, a mortality of 0.07%. The death
occurred in a 19-month-old boy who was
admitted to the hospital in May, 1944. He was at first thought to have pneumonia and
otitis media. Four clays after admission, a
subdiaphragrnatic abscess was drained. In
July an appendectomy with drainage was
performed. In November, 1944, after
drain-age of a brain abscess he died. There has
been no death during the past 12 years,
that is, in the last 1,309 consecutive cases
of appendicitis.
The age distribution of the present series
is silown in Table I. Only 0.4% were less
than 1 year of age and only 3.9% were less
than 2 years of age. Tile frequency of rup-tore of the appendix is silown for each
group. The younger the child, the greater
the likelihood of rupture. Of the total group 45% had a ruptured appendix. Although the first 2 years of life is tile time when
appen-dicitis is least common, it is tile age in
which it is most lethal. This is due to the
bizarre clinical picture which appendicitis
presents in these small subjects and hence,
* The one death was in this group of Patients.
the delay in diagncsis resulting in high
in-cidence of rupture and subsequent
comphi-cations.
The average hospital stay for each type
of appendicitis is shown in Table II. For
unruptured appendicitis the stay was
slightly less than 6 days and when the
ap-pendix had ruptured the average stay was about 12 days. The figures given are the
averages for the entire series and are
slightly higher than for the past few years.
The present mortality as compared to the
mortality report in previous series from this
institution is shown in Table III. This
closely parallels the decrease in mortality
occurring in adults with appendicitis
re-ported in recent years. It is of interest that
there has been no appreciable change in
the percentage of ruptured appendices over
the same period of time.
The complications which have occurred
in this series are listed in Table IV. The
TABLE II
RELATION OF TYPE OF APPENDICITIS TO DURATION OF HOSPITALIZATION
Type
Duration of
IIo.spztalizatwn (days)
Acute unruptured 5.95
Acute ruptured with peritonitis 11 .89
Acute ruptured with abscess 13.58
TABLE III
RELATION BETWEEN TYPE OF APPENDICITIS AND MORTALITY RATE AT ChILDREN’s HOSPITAL,
BOSTON, BETWEEN 1928 AND 1957
Period Type of Appendicitis Cases Deaths
July, 1944-,Jan., 1957
(Present series)
Totals 848 272
234(45.2%)
Totals 506
2
24
26
1
7
8
0
I
Totals 1,358
‘l’otal Abscesses
244 APPENDICITIS
Total Number of Complications
,Jan., 198-Jan., 1939 (Hudson atid Chamberlain1)
.Jan., 1939-Jut, 1944
(Scott and Ware2)
Acute unruptured
Acute ruptured
Acute unruptured
Acute ruptured
Acute unruptured
Acute ruptured
475
373 (43.1%)
747
611 (45.0%)
Mortality
o.4% 6.43%
8.06%
0.36% .99%
1.58% 0
0.07%
0.07%
number of complications is higher than one
would expect from comparison with series
of this size in adults. The reason for this is
the much larger number of ruptured
ap-I)endices in the childhood age group.
Al-most all the complications occurred in the
group of 611 patients with ruptured
appen-dicitis.
The most common complications were
ab-TABLE IV
COMPLICATIONS
Abscess:
Pelvic Wound Abdominal
Subdiaphragtnati
Subhepati Brain
Intestinal obstructions
Iletnaturia (IlIe to sulfad lazitte Fecal tistula
Pleural effusion Pneumonia Atelectasis Ilematoma
Incisional hernia
Febrile convulsion
Ether convulsion
Purpura
scesses and other infections. Most of the
pelvic abscesses either ruptured
spontane-ously into the rectum or vagina or
sub-sided with antibiotic therapy. The majority
of the wound infections were stitch
absces-ses or other minor infections which did not prolong the patient’s hospitalization.
Postoperative obstructions were also
fre-quent. Of the 45 instances of small bowel
obstruction, 44 occurred during the
imme-diate postoperative period. The other
oc-curred 6 months after appendectomy and
drainage. This group of obstructions, which
occurred 5 to 10 days after operation for
ruptured appendicitis were almost always
8 due to edema and the acute inflammatory
o
process present in the right lower quadrant.S If these patients can be tided over until the
inflammatory process subsides, the
obstruc-tion will be relieved. Forty of these patients
io were treated with intestinal decompression
by means of a Miller-Abbot tube and no
#{176} additional operative procedure was
re-quired.
4 Secondary operative procedures were
re-4 quired in 49 instances (Table V).
Twenty-4 two of these were for drainage of abscesses.
The eight cases of interval appendectomy
occurred early in the series when no
par-i ticular effort was made to remove the
ap-i pendix in cases of appendiceal abscess. Five
of the patients with intestinal obstruction
ARTICLES 245
‘I’ABLE V
5EoNoAIIY OPERATIONS
I)rainage of Al)sCesses:
\\ound
Pelvic
Intra-al)doniinal
Suhphretiic Subllepatic Brain
Iliterval appell(le(totnv
Lysis of a(lhesioIIs
\Vitzel enterostoiny
(‘losure of fecal fistula
l.vacuatioll of alitloininal heniatonia
Incisional herniorrhaphy
Total 49
of tile obstruction. Early in the series
Wit-zel enterostomy was done on one occasion.
The case of obstruction which occurred 6
months postoperatively had immediate lysis of adhesions. There were three patients whose obstruction occurred in the immedi-ate postoperative period who did not re-spond adequately to tile Miller-Abbot tube therapy and had to have lysis of adhesions.
Other secondary operative procedures were
one each for repair of incisional hernia and
evacuation of abdominal hematoma. Two
of the fecal fistulas closed spontaneously;
tile other two were closed surgically.
SUMMARY
The results of the experience with all
cases of acute appendicitis occurring on tile
Surgical Service at Boston Children’s
Hos-pital between July 1, 1944, and January 1,
1957, are presented. There were 1,358 cases.
Early diagnosis is of the utmost
impor-tance, although in small children this may i)e very difficult.
Prompt appendectomy is the treatment
for all children with appendicitis. The
im-portance of adequate preoperative
prepa-ration and postoperative care of the sicker
children is stressed. If appendiceal rupture
has occurred, the appendix is removed and
the abdominal cavity is drained.
Of 1,358 cases, 611 (45%) had ruptured
;i;ipendicitis. There was one death, a
mor-tality of 0.07%. There have been no deaths
in tile last 12 years, during whicil 1,309 pa-tients Ilave been treated.
The most common complications were
I I residual infections and obstruction of the
small bowel. Most of the immediate
post-operative obstructions could be managed
4 with a long intestinal tube.
The fact that nearly half of the patients
S had rupture of the appendix before the
time of hospitalization is strong proof that
much has yet to be accomplished in
im-proving the early recognition of this disease,
thus permitting surgery to be performed
before rupture and penitoneal soiling has
occurred. The most important effort that
can be made in this direction is (when the
local physician cannot make frequent house
calls to a sick child) to recommend 24 or
48 hours of observation in a hospital for any
child in whom appendicitis is suspected. At
little expense, this allows frequent checking
by appropriate members of the resident or
visiting staff of the hospital. If findings
sug-gestive of appendiceal inflammation
disap-pear, the child generally can be sent home
the following day. For those in whom the
abdominal findings become more impressive
under observation, operation can be
under-taken while there is still an opportunity to
do so before appendiceal rupture has taken
place.
SELECTED BIBLIOGRAPHY
1. Hudson, H. W., Jr., and Chamberlain, J. W.:
Acute appendicitis in childhood. J. Pediat., 15:408, 1939.
2. Scott, H. W., Jr., and Ware, P. F.: Acute appendicitis in childhood. Arch. Surg.,
50:258, 1945.
3. Cross, R. E.: The Surgery of Infancy’ and Childhood. Philadelphia, Saunders, 1953, p. 253.
4. Slatterv, L. R., Yannitelli, S. A., alld
un-ton, J. W.: Acute appendicitis. Evalua-tion of factors c3ntrlbuting to the decrease in mortality in a municipal hospital over a twenty year period. Arch. Surg., 60:31,
1950.
5. Wangensteen, 0. H., and Dennis, C.:
Ex-perimental proof of the obstructive origin
246 APPENDICITIS
6. Meagher, S. \V., Crandon, J. H., and
Camp-l)ell, A.
J.
A. : Appendicitis in children.New England J. Med., 250:895, 1954.
7. Foster,
J.
H., and Edwards, W. H. : Acuteappendicitis in infancy and childhood: A twenty year study in a general hospital.
Ann. Surg., 146:70, 1957.
SUMMARIO IN INTERLINGUA
Appendicitis In Le Pueritia
Appendicitis in he gruppo de etate pediatric
es del prime importantia a causa de su alte
frequentia e le negligibile mortalitate in casos
adequatemente tractate. Le presente articulo
reporta le resultatos in 1.358 provate casos de
appelldicitis tractate al Servicio Chirurgic del
Hospital de Juveniles a Boston inter le 1 de
julio 1944 e le 1 de januario 1957.
Un accurate e prompte diagnose es le plus
importante factor individual in le cura de
pa-tientes con appendicitis. Le triade de dolor
abdominal, febre, e vomito debe esser
con-siderate como indication de appendicitis usque
511 non-existentia pote esser demonstrate. Le
histonia-specialmente in juvenissime patientes
-es frequentemente vage, e grande importantia
debe esser attachate al constatationes physic.
A vices le examine del abdomine pote esser facilitate grandemente per le uso de sedation per barbituratos. Sensibihitate sub pression es
he plus constante constatation objective e
oc-curre usualmente in le quadrante
dextero-inferior. Un meticulose examine physic es in-dispensabile pro excluder le numerose altere
causas de dolores abdominal in juveniles. Un
examine digital del recto collciude he examine.
Si le diagnose remane dubitose al fin del
examine, he patiertte deberea esser tenite sub
observation durante plure horas. Si he patiente
suifre vermente de appendicitis, he diagnose
va tosto clarificar se. Si he dolores resulta de
on altere causa, iste facto deveni generalmente
evidente, e multe operationes illllecessari pote
esser evitate.
Le tractamento appendicitis es he
prompte effectuation de appendectomia. In
non-complicate casos de appendicitis sin rup-tura del appendice e de breve duration he
pre-1tration preoperatori es simple. Si le juvene
pa-tiente ha un appendice rupturate e peritonitis
C Si ille es dishydratate e febril, on intense
tractamento preoperatori es necessari. Isto
con-siste de hydratation per medio del appropriate
fluidos, reduction del febre, sedation, e le uso
de antibioticos.
Le anesthesia que es generalmente usate es
guttas de ethere a administration aperte. Si le
patiente es multo malade, cvclopropano es
usate. Si le appendice es rupturate, illo es exci-dite, e he cavitate abdominal es drainate
rou-tiflarimellte.
Le post-cura in casos de non-complicate
ap-pendicitis presenta usualmente niulle problema.
In casos de appendices rupturate, le cura
post-operatori consiste del uso del position de
Fowler, sedation, suction naso-gastric, fluidos
intravenose, antibioticos, e frequentemente
transfusiones de sanguine o de plasma.
In he curso de un periodo de 123& annos,
1.358 juveniles con appendicitis provate esseva
tractate al Servicio Chirurgic con un sol morte.
Isto representa un mortahitate de 0,07 pro
cento. Iste morbo non es commun durante he
prime 2 annos del vita, sed a iste etate illo es
he plus letal. In le gruppo total, 45 pro cento
Ilabeva appendices rupturate. In he curso del
passate 30 annos, ii ha occurnite un continue
reduction del mortahitate in casos de
appendi-ctis, sed he procentage del casos COfi ruptura
del appendice non ha descendite.
Le plus frequente complication esseva in-fection e formation de abscessos. Obstructiones
postoperatori del intestino tenue non esseva rar
post appendicitis con ruptura del appendice.
Quasi omne he obstructiones occunrente durante
le periodo immediatemente postoperatori
p0-teva esser manipulate per medio de un longe
tubo intestinal.
Le facto que quasi un medietate de nostre
patientes habeva ruptura del appendice ante
Ic tempore de ion hospitalisation representa on
forte prova pro le assertion que multo remane
a facer in mehiorar he recognition precoce de
iste maladia, con le objectivo que le
effectua-tion del operation chirurgic deveni possibile
ante he occurrentia de ruptura e de infestation
