DISEASES OF THE APPENDIX Tuberculosis of the appendix, seldom primary, enters little into this discus.sion, save as general or intestinal tuberculosis, especially of the eecal region. The complaints and symptoms are as a rule the same as those of intestinal tuberculosis. Yet cases are known in which a typhlitic tumor was palpahle in this region, causing pains and marked symptoms. In general, these cases are of slight practical significance. They are lieSelibed under intestinal tuberculosis.
Historical.—The most common disease of the appendix is of the inflammatory type (typhlitis, peri- or epityphlitis, appendicitis, periappendieitis, skolikoiclitis, periskolikoiditis). The more exact knowledge of this disease of the vermiform extension of the intestine and its surroundings, is an acquisition of the last ten years of the past century. Indeed, diseases in the region of the eecum (typhlitis stereoralis) 113•111 101011'11 to the older physicians CAretarms, Ceisus, Norgagnil. There were physicians even in the first half of the past century who denied that intestinal obstruction was the chief factor of this disease, and claimed that the disease originated not in the ceetum but in the processns vermiformis itself. 1Ve have gained a more exact knowledge of the origin and course of the disease since the early and frequent operations have made possible, as it were, an autopsy during life (Sonnenberg, 1894) and from the more frequent post-mortem examina tions. These confirm further the knowledge which was early established that childhood is quite often attacked by this disease (seven times more frequently than adults, Seller). This is explained by the anatomical and physiological peculiarities of infancy.
The progress of this disease children depends on the anatomical and physiological peculiarities of childhood, as well as the organ and 213 its surrounding tissue. Appendicitis occurs so frequently that it should be formally designated as a disease of childhood (Sonnenberg, Karewski, iSelter).
General disease manifests itself at the beginning, or close, of a digestive disturbance by cramps, a feeling of fnlness, and pains in the right hypogastric region. There is often associated,
according to the severity of the attach, nausea, vomiting, constipation or diarrheca; a sense of pressure in the region of the appendix: sw-el ling, pain and rigidity of the abdominal wall, or of a part thereof, especially the eecal region, and eventually a palpable tumor; many more-or-less threatening, phases of suppuration and of septictemia may appear later.
The conditions will be explained by a study of the pathological changes in the appendix and its attachments. Only in the rarest eases cloes the cecurn show itself to be the site of the disease, and then only under entirely different cireumstanees: as, for instance, perforation as a result of swallowing a foreign body. Clinically, there are then pre sented the same symptoms as in perforation of the appendix.
Normal appendix of the child is, as a rule, loeated with its distal end low- down in the pelvis, because of its length and the deep position of tile cecum on the shelving part of the ilium. In rupture of the organ it is usually found internally and mostly in the depression between the psoas muscle and tlw spinal eolumn. Only in the less fre quent torsions, or where the insertion is posterior, is its course toward the lumbar region. TM.se anatomical eonsiderations are of great importanee in determining, the position of perityphlitie exudates (Scher). The younger the child, the larger and shorter in connection with the intestine is the insertion of the appendix (percentage of the length of the process to that of the larger intestine in the newborn, 1:10; in adults, 1:20, Ribbcrt). Seybalous masses, carriers of infection, as well as secretions can for this reason more easily enter and make their exit from the appendix.
The mucous membrane of the appendix is rich throughout in lymph nodes and erypts. The younger the subject the richer the crypts. These crypts inerease in number until they enter the submueosa.