The following classification proposed: The appendix is the most vulnerable of the abdominal organs because of its deficient blood-, nerve-, and lymphatic supply, its length and calibre, and be cause of its liability to traumatism in its association with the psoas muscle. The majority of cases are of a chronic nature, and not infrequently the whole pathology of appendicitis is demon strated in one patient. Obliteration of the lumen of the appendix is rare and never to be relied upon. The rapidity and suddenness with which the organ may become diseased and gangrenous, giving rise to a fatal peritonitis, empha sized.
The three principal symptoms are pain, tenderness, and rigidity. The most important of these, pain, is parox ysmal, and may, at intervals, almost dis appear. Its location entirely depends upon the position of the appendix. It is well to always palpate at a point some distance from the supposed seat of disease and then gradually approach the point of tenderness. Abrupt cessa tion of pain implies gangrene. Both temperature and blood-count are of little value as diagnostic signs. J. B.
Deaver (Jour. Amer. Med. Assoc., July 13, 1901).
In one hundred and forty-six cases collected by Matterstock perforation was found to have occurred one hundred and thirty-two times.
The complications following perfora tion vary. Normally the peritoneum completely surrounds the appendix and the cacurn, and a localized peritonitis and a perityphlitic abscess necessarily follow.
If, however, through previous local in flammation, close adhesions have united the appendix and the peritoneum, both organs are perforated simultaneously, and the appendical contents may pass entirely through the peritoneal coats. This gives rise to an extraperitoneal abscess, which may open externally above Poupart's ligament or within the abdomen into the small intestine, the bladder, the vagina or the rectum, the portal vein, the iliac artery, etc.
Infection of the retroperitoneal glands and lymphatics and of the portal vein is much more frequent than is gen erally believed, and leads to perirenal abscess and sinuses in the loin or groin. When a case in which good drainage has been secured shows a persistent eleva tion of temperature, this complication should be thought of if the chest, kid neys, and pelvic organs can be excluded. Portal infection, with tenderness, jaun dice, and general malaise, usually calls for operation. Hepatic tenderness and sepsis imply a possible portal phlebitis.
Mild infections both of the lymphatics and of the portal system occasionally yield to medical treatment. Persistent fever, without other evident cause, should suggest one or both of these in fections. Drainage in the loin gives prompt and satisfactory relief, even where pus or a diffuse cellulitis has formed. Prompt and thorough drainage of the liver, together with the removal of the inflamed appendix, offers the best means of recovery from septic infections of the liver. Aspiration of the liver is an imperfect procedure. Abdominal sec tion with free exploration and free opening of all abscesses within reach is less dangerous and much more satisfac tory. J. V. Munro (Therap. Gaz., J'an. 15, 1901).
Two cases complicated with phlebitis of the left leg. In one case pain in the left leg occurred the second day, fol lowed by dyspnoca and fever on the third. A day later marked phlebitis appeared. Cough with bloody expecto ration followed, with all the signs of a pulmonary infarct. The second case was one of purulent appendicitis and phlebitis. Two other cases referred to. Of the four, two died. A peculiarity is that it occurs more frequently on the left side. It is evidently due to metas tasis through the circulation. Its oc currence makes the prognosis unfavor able. Willard and Vignard (Revue de Chir., Jan., 1901).
Two cases of thrombosis of the fem oral veins following appendectomy. Ex cessive pain in the left groin, followed a few days later by cedema of the leg and the infiltrated vein, were the main signs. Infection is probably the causa tive factor of this complication rather than the mechanical theory of Lennan der. W. Meyer (Annals of Surg., May, 1901).
Pleurisy observed 34 times in 89 cases. In the 34 cases but 1 presented the com plication on the left side. When bilateral pleurisy does present itself the right pleura is the first affected and contains the largest effusion. Wolbrecht (These de Lyon, '93).
Out of l5 cases recorded 3 were of the dry form, in 29 the effusion was serous, while in 13 the liquid was purulent, with marked dyspncea and intense fever. The prognosis of the appendicitis is only affected by the pyfemic form of pleurisy, the serous form frequently disappearing of its own accord. The lungs should be carefully watched in all cases, therefore, lest the aggravated pleurisy intervene to serously compromise the result. Croizet (These de Lyon, '93).