DIFFUSE ABSCESS.—If an abscess has opened into the peritoneal cavity, caus ing diffused septic peritonitis, a good sized incision is made parallel to the border of Poupart's ligament, the peri toneal cavity is opened, and the con tained fluids are removed. The appen dix is removed; further collections of fluid are looked for and withdrawn with a sponge on a handle. The cavity is washed out with a saline solution and drainage is provided for by a glass tube with a capillary gauze drain. The wound is left open, but no suturing is practiced. Nutrition by rectum for a day or two. The deep packing is not disturbed for four days. (111cBurney.) In twenty-four cases treated by the above procedure fourteen recoveries ob tained. McBurney (N. Y. Med. Record, Mar. 30, '95).
Relapsing Form.
Symptoms.—The symptoms of an ex acerbation are the same as in the acute form. The simple catarrhal form may be suspected when the recurrences happen more than four or five times, and last not more than a week and no tumor is felt.
The ulcerative form with its attend ing danger of perforation may be sus pected when a tumor is felt in the inter val, and especially when the tumor has increased in size during the access.
In fifty-seven cases of simple appendi citis, fifty-two showed appendicular per foration with abscess of surroundings.
In eighty cases twenty presented at least one previous attack. Mathieu, Sonnen burg (Gaz. des. H6p., Dec. 1S, '94).
Perforation the rule in recurrent cases; the adhesions rupture, often without giv ing any sign, the patient dying of sub acute peritonitis. Several instances in cases supposed to be cured. Broca (Bull. de Is Soc. Anat., Dec., '94).
Etiology and Pathology. — The large majority of the attacks are due to any cause which may awaken the latent catar rhal process resulting from a previous attack treated medically. The patholog ical characters are the same as in the acute form, except in the fact that adhe sions are likely to be found if anything but a very mild attack has previously occurred.
There is a class of cases, "appendicitis obliterans," a comparatively frequent relapsing form, which is characterized by progressive obliterations of the lumen of the appendix. Ribbert found in four hundred post-mortems (death being due to other causes than appendicitis) par tial or complete obliteration in .25 per
cent. Senn (Jour. Amer. Med. Assoc., Mar. 24, '94).
Instances in which there is only one attack are much more numerous than those in which there have been several attacks. The great majority of those who have passed through the stage of suppuration are rendered free from fur ther attacks. Treves (Brit. Med. Jour., Mar. 9, '95).
After one attack the appendix is fre quently as fully capable of originating another attack. Stimson, Bryant, Fow ler (Annals of Surgery, May, '95).
1. The chief agents in producing re lapsing or recurrent appendicitis are micro-organisms latent in the thick walls of the vermiform appendix, in the strictures, and in the cicatricial tissue. and adhesions both peri-appendicular and parietal.
2. Alteration and enfeeblement of the walls of the appendix; as by infiltration of fat, and new formation and dilatation of vessels, which readily favor both act ive and passive congestion or add to the results.
3. Certain appendices, apparently "healed," have some abrasion of the mu cous membrane, which easily explains the presence of bacteria in the tissues, and by their development a reinfection is occasioned. Ch. von Mayer (Revue Mad. de la Suisse Rom., Apr. 20, '97).
In almost all chronic cases unattended by abscess or inflammatory adhesions, there is, first, a bend, or flexure, of the appendix; second, at the point of flexure there is also a stricture; and, third, dis tal to the stricture is marked distension of the appendix and great thickening of its walls. Supposing that the bend in the appendix is the first step in appen dicitis, the bend embarrasses the escape of contents. To empty itself, the mus cular walls are compelled to perform extra work, producing a very marked muscular hypertrophy. As a result of the pressure caused by the effort of the appendix to empty itself, the mucous coat at the point of flexion becomes eroded and inflamed, and functional stricture finally terminates in an organic stricture. This gives rise to recurring attacks of pain, which ceases when the appendix has discharged its contents. After a time, the organ is no longer able to empty itself. Distension, perforation, and peritonitis then follow. D. P. Allen (Med. Record, June 5, '97).