TYPHLITIS AND PERITYPHLITIS.
its appendix are liable to disease on account of the tendency to retention of foreign bodies and irritating substances in this part of the alimentary canal. In perityphlitis, the inflammatory process begins almost invariably in the mem, and spreads thence to the loose areolar tissue around it. In most cases, it is the consequence of ulceration and perfora tion of the wall of the mecum or vermiform appendix.
Causation, etc.—The form of perityphlitis which is due to ulceration of the vermiform process seems to occur more often in early life than in later years. Therefore, childhood may be considered to be one of its predispos ing causes. It has been noticed in an infant no more than seven months old ; but this is very exceptional. Usually, the child is between four and twelve years of age. It is said to be more common in boys than in girls.
The determining cause of typhlitis is, no doubt, in most cases, constipa tion, with retention in the coecum of hardened Neal matter, constituting what Rokitansky named " typhlitis stercoralis." It has, however, been also attributed to cold and external injury. I have known it to occur during convalescence from typhoid fever.
Perityphlitis is commonly due to the passage into the appendix of a lit tle concretion, which is retained and sets up inflammation and ulceration. Hardened intestinal concretions are often described from their appearance as cherry- or date-stones, but on examination are almost invariably found to consist of the earthy phosphates combined with inspissated mucus and or dinaa-y faecal matter. They may be formed around small foreign bodies, as a shot, a pin, or a spicula of bone. In size, they may resemble a pea or a date-stone. They have a smooth, shining, waxy-looking surface of a gray ish or brownish colour. Their consistence is hard, and their structure often. laminated. Sir William Jenner is of opinion that the retention of these cal culi is due in many cases to malposition °Utile appendix. This process, owing to its length and the attachment of its mesentery, may be bent at an angle (instead of being directed upwards and inwards), so that hardened particles can slip readily into it but are prevented from returning. Accord ing to Dr. Sands, the appendix, before destruction of its coats, contracts ad hesions to the peritoneum lining the iliac fossa ; so that when perforation occurs, the faecal matters, instead of entering the serous cavity, gradually pass into the loose connective tissue which lies outside the peritoneum.
In some cases, a typhoid or tubercular ulcer may lead to destruction of the wall of the mecum, or the part of the intestine immediately adjoining, and be a cause of extravasation. When the escape of faecal matter takes place into the loose tissue behind the cacum, it sets up inflammation and abscess. An abscess once formed rapidly enlarges, and tends to point some where in the iliac region, or in the groin just above Poupart's ligament. The direction in which the pus travels, varies according to the exact seat of the purulent collection. Thus it may pass along the inguinal canal into the scrotum, or along the psoas and iliac muscles to the upper part of the thigh. Sometimes it dips into the pelvis, and opens into the rectum. In other cases, if the ulcerated opening remain patent, the pus may pass. through it into the mecum ; but often after a time the opening closes up so as to shut off all communication with the abscess.
Often, general peritonitis, more or less severe, accompanies the peri typhlitis, from extension of the inflammation. If, instead of opening into the sub-serous tissue, the rupture takes place from the bowel or appendix directly into the peritoneal cavity, peritonitis is set up at once.
Symptoms.—An attack of typhlitis begins suddenly with pain localised in the right iliac fossa ; the child vomits, and the bowels are confined. The pain is constant, and apparently severe. It is increased by pressure over the mecum, by cough, or by efforts to vomit. The matters ejected consist of watery and bilious fluids, and the retching may be severe and distressing. At the same time, there is fever which varies according to the nervous im pressibility of the child. Usually, the thermometer marks 101° or 102°. The expression of the face is anxious and distressed. On palpation of the belly, we notice a firm mass in the situation of the mecum, and gentle per mission at this spot elicits a dull sound. On account of the tenderness, it is difficult to make a satisfactory examination of the iliac region, for the least touch causes severe suffering. The child lies on his back, inclining to the right side ; he flexes his thigh, and cries bitterly if any attempt is made to straighten the limb. Sometimes a distinct swelling may be noticed at the seat of pain.