Appendicitis almost always precedes an attack of peritvphlitis or paratyphli tiQ Records of one hundred post-mortem examinations, 91 per cent. of which showed that the disease had started in the vermiform appendix. Primary per foration of the cfecum was observed in only 9 per cent. of the cases. Eichorn (Mtinchener med. Woch., Nos. 7 and S, '91).
The affection may start either in the ecuin or the appendix, but with marked predilection for the latter. Herman iNfynter (Deutsche med. Woch., Apr., '91).
In three hundred and twenty-fou• eases the appendix was found to be the seat of the disease two hundred and eighty-two times. The importance of the appendix as a starting-point for disease is beyond dispute. Hartley (N. Y. Med. Jour., June 25, '92).
Post-mortem records at Munich fully bear out the generally received idea that the appendix is primarily involved. Haenel (Mfinchener med. Woch., Mar. 26, '95).
Pathology of Various Forms. — The simple catarrhal form is usually caused by constipation or indiscretion in diet, in which the inflammatory process, after passing through an acute stage, includ ing more or less epithelial desquamation, excoriation, etc., and involving the mu cosa, submucosa, and the serous layer and the overlying area of peritoneum, gradually recedes. The appendix re mains very vascular and functionally -weakened, and is subject to renewed of inflammation.
The ulcerative form, in which the in flammation is usually produced by fmcal concretions or foreign bodies, gradually proceeds to ulceration. An opening be comes formed near the apex of the organ and the fecal concretion or foreign body escapes, with the septic discharges formed, into the abdominal cavity.
The majority of primary attacks of appendicitis occur through an eroded mucous membrane, caused by masses of fxcal matter. rarely by a foreign body.' Focal matter is introduced into the lumen of the appendix by contractions of the mcum. The expulsive force of the appendix is not sufficient to expel it, and hence it remains to irritate the mucous layer, at first merely by its presence. The slight muscular move ments of the appendix tend to mold the mass into a round or oblong shape. This mass is augmented by the natural secretions of the mucous membrane of the appendix and by further accessions of fcal matter from the ccum. Grad
ually the concretion increases in size until it irritates by causing pressure against the walls of the organ. This is followed by a decided erosion of the mu cous membrane, and this by an invasion of the micro-organisms which are always present in matter. They prolif erate, and the inflammatory troubles then begin. In a few cases the increased secretion of the mucous layer may cause partial liquefaction of the fxcal con cretion, which may be expelled. In the majority of cases, however, the concre tion remains in the lumen, where it is found to act as an exciting cause of further inflammatory trouble. J. B. Deaver (Amer. Jour. Med. Sciences, Aug., '97).
Anything that could remove the epi thelial lining from the mucous membrane of the appendix might be the starting point of the mischief. G. A. Armstrong (Lancet, Sept. IS, '97).
The idea embodied in the word ca tarrhal appendicitis is a correct one in the very early stages in the morbid con dition. Excluding the rarer cases when foreign bodies are entrapped, or in which there is kinking of the appendix from its short mesentery, the origin of the stricture is found in one of two causes: septic and linear ulcer or the contrac tion of the catarrhal inflammation, antedating this stricture by many years. From this study it may be said with certainty that the first attack of appendicitis recognized by the patient is in most cases the end of the disease, for the appendix shows the presence of a stricture which may have existed for many years. The most complete experi ence clinically of the variations in the symptoms is often required to differ entiate between the disease in question and so unlike a malady as typhoid fever. The latter study of leueocytosis throws much light upon the differential diagnosis. Attacks may often be cured by natural methods; that a long re spite does not mean a cure, and that it is impossible to predict a cure; and, finally, that, unless the appendix is re moved, the disease is always latent where once it is begun. Robert Abbe (Med. Record, Feb. 16, 1901; Phila. Med. Jour., Feb. 23, 1901).