Pleurisy is generally a local complica tion, a pleural abscess by contiguity. While metastatic pleurisy may coincide with infarct on either side, the latter will be upon the right side always, pre ceded and accompanied by subphrenic suppuration. In 13 cases from the liter ature, right-sided pleurisy was found post-mortem with subphrenic abscess, showing the extension from the appen dix through the diaphragm into the pleura. The physical signs simulate purulent pleurisy. The prognosis is grave; the diagnosis always difficult. L. Lapeyre (Revue de Chir., May, 1901).
If there is no adhesion between the appendix and the peritoneum suppura tive peritonitis is produced, and this process usually gives rise to a protective plastic exudation, which causes the sur rounding loops of small intestine to ad here together and inclose the secondary abscess, thus temporarily protecting the surrounding parts.
If, however, the plastic inflammation does not induce protective adhesion be tween the intestinal loops, the septic material invades the whole peritoneal cavity, and gives rise to diffuse and fatal peritonitis.
Case of appendicitis complicated by acute parenchymatous nephritis. Prob ably due to fact that the toxins gener ated by the virulent coli communis irri tate the renal epithelium. Moldayski (Vratch, May 12, 1901).
Forty-five eases of subphrenic abscess as a complication of appendicitis col lected from literature and personal case show that the complication is a very rare one and that many were not diag nosed until after the death of the pa tient. It may be extraperitoncal or in Pleurisy, due to propagation of the in flammation through the retroperitoneal cellular tissue, or through the lymphatic system, is an occasional complication, but often passes unperceived. It is almost invariably on the right side, and is rarely bilateral.
traperitoneal. J. McF. Gaston (Med. Record, Mar. 23, 1901).
When appendicitis is protracted, a fa cal fistula often results. In one of three fatal cases of perforation of the etecurn following appendicitis, fmcal mat ter escaped and formed a circumscribed peritoneal abscess, between the folds of the small intestine. In the other two perforation occurred in the cxemn, cir cumscribed abscesses being also found. When appendicitis is protracted, the mesenteric glands swell and peritonitis may follow. As ffecal matter may enter the peritoneum, an early laparotomy will be necessary. E. Rose (Deutsche Zeit. f. Chir., Feb., 1901).
Prognosis. — Death may occur very early, especially in children, who are also more liable to peritonitis than adults. The danger of death is greater in men than in women.
It is in the first twenty-four hours from the beginning of the attack that we can decide not only as to the diag nosis, but as to the probable course and result of the case. If in five or six hours there is no increase in urgency, the pa tient is not in immediate danger, kept at perfect rest in bed; if in twelve hours there is still no increase in the severity of the symptoms, the patient should soon begin to improve. If the urgency of the case has steadily increased in twelve hours from the time when the diagnosis Al as made, an operation will probably be called for. After two at tacks a patient is sure to have a third, and each attack renders operation more difficult and dangerous. All the advan tages lie with operation between the attacks. In an operation during an acute attack the prognosis is worse. McBurney (Med. News, No. 24, '96).
Conclusions based on 213 personal cases:— I. Cases with early fever (104° F.), with defervescence on third or fourth day, recovered rapidly.
2. Similar onset, but more prolonged fever, with fall of temperature about the fifth day to 102° F. Of 14 cases, 3 were operated on for abscess and all cured.
3. Temperature after fifth day still over 102° F.: infection virulent and prognosis unfavorable. Of 11 such eases 2 died, 2 were cured without operation, 4 were operated on, and 3 recovered after long illness due to perforation into the bowel.
4. Recurrence of fever after early de fervescence. Of 6 such eases 4 were oper ated on; 1 died from peritonitis.
5. General peritonitis, with serious in fection, low temperature. In these cases the state of the pulse gives indications as to the severity of the disease. J. Rotter (Centralb. f. Chir., Oct. 24, '96).
Reference made to 32 cases of appendi citis during and after pregnancy, 4 of which were personal. In the 32 cases there were 10 deaths, a percentage of 31, which is much higher than that of Armstrong in his series of 517 cases, with a mortality of 12.8 per cent. The only complication of importance in appendi citis occurring during pregnancy is abor tion, noted in 40 per cent.; this accounts for fact that in half the 32 cases the chil dren died. Appendicitis during preg nancy should be treated like ordinary appendicitis. Vinay (Lyon MM., Jan. 2, '98).