Cases of ulcerative perforation of the vermiform appendix require spe cial mention. This accident is, as has been said, more common in early life than after adult age has been reached. Often, the initial stage of the dis ease has excited no notice, and the first symptoms that arise are due to the extravasation of the contents of the bowel into the peritoneum. In most cases, all the symptoms of acute peritonitis ensue, and the child rapidly dies. The consequences of the extravasation are not, however, always so easy of recognition. In the chapter on Acute Peritonitis, mention is made of the occasional latency of the abdominal symptoms in cases where the peritoneum is inflamed. This is sometimes the case when the inflamma tion is set up by mattets extravasatecl from the bowel ; and we may find, as a result of perforation of the appendix, merely pain, vomiting, constipation, and some fever—symptoms which are not characteristic of peritonitis, but tend rather to suggest obstruction of the bowel. In fact, not once, but many times, such cases have been treated for obstruction, even to the extent of actual surgical interference. The obstinacy of the constipation, the per sistency of the vomiting, and the colicky character of the pain, make the resemblance curiously close. Often, indeed, very careful examination is re quired to detect the real nature of the attack. It is of extreme importance to remember that traumatic peritonitis in the child may be ushered in by such symptoms ; and in every case of supposed obstruction of the intestine, we should search carefully for some other cause for the illness.
Sometimes, on inquiry we find that on previous occasions the child had complained of slight abdominal pain, lasting for twenty-four hours, or perhaps two days, with tenderness in the ccal region and a single effort of vomiting. These passing attacks may be accompanied by flatulence, constipation, or diarrhcea, and a feeling of distention of the belly. They are due, no doubt, as Dr. With has pointed out, to ulceration of the vermi form appendix, with commencing adhesive peritonitis. After perforation has occurred, the local symptoms may remain limited to the iliac region, or may spread to the whole abdomen. In the first case, if the disease be recognised and properly treated, the child may perhaps recover ; in the second case, he usually dies. Rens may occur before death.
Diagnosis.—Typhlitis is accompanied by such characteristic symptoms that its detection is not a matter of difficulty. A sudden attack of abdom inal pain and tenderness referred to the region of the right iliac fossa, accompanied by vomiting, constipation, a pinched, anxious expression, and some fever, at once draws attention to the belly. On examination, the presence of an intensely tender swelling in the situation of the cmcum, together with the drawing up of the thigh on the affected side, sufficiently indicates the nature of the illness. If the occurrence of vomiting and obstinate constipation, combined with a localised swelling and severe abdomiiial pain, should suggest intussusception, we may remember that in the latter disease'tenderness and signs of local peritonitis are not early symptoms ; that the tumour, if felt, is commonly detected on the left side of the abdomen ; and that violent straining, with the passage of bloody mucus, is a very constant and prominent symptom.
If, after the signs of general constitutional disturbance have subsided, the local symptoms do not disappear, but more or less tenderness, pain, and swelling persist ; or if, after disappearing, the acute symptoms return after only a short interval, and this recurrence happens several times, in either case we have reason to fear that the inflammatory process is going on to ulceration. The occurrence of peritonitis at this time will confirm our apprehensions, and indicate extravasation into the cavity of the peri toneum. If, however, the wall be perforated posteriorly, and an abscess form behind the cmcum, the symptoms are much less striking.
If the patient be not confined to his bed, he often complains of tender ness in the right groin, and halts upon the right leg. The case is then distinguished from hip disease by noticing that although the child keeps the thigh partially flexed, and is greatly distressed when any attempt is made at passive extension, the head of the femur may be rotated readily and without pain, if it be done with care ; and that pressure upon the hip joint on or behind the trochanter, causes no discomfort if the patient's whole body be not jolted at the same time. Often, the child, while lying on his back, will readily flex the thigh, and perform the movements of abduction and adduction. It is only extension which appears to be im possible, and any attempt to straighten the limb causes severe pain. It will be remarked, too, that while the history indicates shortness and acuteness in the illness, the symptoms, if they could be referred to the hip-joint, would suggest disease of considerable duration. Lastly, wasting of the muscles of the thigh, which occurs early in acute hip disease, is absent ; the gluteal muscles on the affected side are not flattened, nor is the fold of the buttock lowered ; the fold in the groin below Poupart's ligament is not obliterated ; and distinct swelling and tenderness can be detected in the right iliac fossa.
Directly signs of pointing are noticed, any remaining obscurity in the case must disappear.
Ulceration and perforation of the vermiform process are very difficult to recognise with certainty, as the first symptoms noticed are often those due to the extravasation into the peritoneal cavity. Severe peritonitis coining on suddenly, especially if the pain and tenderness can be ascer tained to have started from the right iliac region, is very suspicious of this accident. Essential peritonitis comes on gradually, and the ordinary forms of peritonitis from perforation are preceded by some severe acute illness. It is important to bear in mind that the phenomena resulting from perforation of the caecal appendix may be far from characteristic of inflammation of the peritoneum ; and in every ease where symptoms arise pointing to sudden obstruction of the bowels (pain, vomiting, and consti pation). accompanied by fever, we should 'carefully exclude this and other possible causes of such symptoms before committing ourselves to the diagnosis of intestinal occlusion.