Pathological Plate 52.) The first signs of the disease appear in the appencliceal tonsil in the same way as we see them on the pharyngeal tonsil of children. At first there is a slight reddening and swelling of the mucous membrane, and above all, of the follicles( desquamation of the epithelium, with or without thrombosis, in the erypts or lacunae. Otherwise there is naturally, according to the :severity of the disease, a more-or-less severe lymphangitis of the wall, with (-edema and cedematous swelling of the submucosa down to the serosa (appendicitis simplex, Sonnenburg).
All these phases may resolve, with or without residues; may- also lead to granulating processes (Riedel) and so to sear tissue and con tractions caused by relapses and chronic processes. In other eases, bacteria wander into the subraueous and muscular coats. The letteocytic accumulations which- then arise may- proceed to pus formation, and produce only- the most trifling changes, except in the mucosa or serosa. Either one or both will be perforated. By perforation of the mucosa, empyema of the appendix results; and by perforation of the serosa, appendicitis perforativa (Sonnenburg). Naturally, these conditions cannot arise without leaving behind their results in the organ. More or less extensive scars, strictures, torsions, and thereby constricting granular processes remain, eausing the retention of enough secretion and scybalous masses to prepare the groundwork for further inflam matory processes (Aschoff).
In more severe cases pseudomembranous lesions are found which lead to more or less deep necrosis of the mucous membrane from the laeunte outwarcl. The changes in the wall of the appendix already described naturally ensue. These often lead to the total destruction of that part of the wall, with perforation and severe, often pustular and inflammatory-, conditions of the surrounding tissue (Aschoff).
During this change, a profuse exudation appears in the lumen of the process, according to the severity of the illness. This exudate may be expelled in milder cases. But in other eases it stagnates and is mixed with fecal material, especially when fecal matter is already present in the interior of the organ. The impregnation of the yvall with inflammatory and necrotic masses is still further localized, and a higher grade of inflammation is produced at this point. The cir culation 111 the wall is influenced by- the pressure of the masses of exudate, with the formation of a thrombosis in the vessels, thus pro ducing partial or total necrosis (appendicitis gangramosa, Asehoff) (see Plate 52).
According to the above, the lumen of the wall of the appendix in most cases remains thickened, and commonly in other cases the serosa of the surrounding tissues participates (periappendicitis). Then, when a plug of toxine (non-bacterial) results, a fibrinous exudate about the appendix and the surrounding coils of intestine appears, or a suppuration of the bacteria-free exudate follows (peritonitis chemicalis). On the entrance, however, of bacteria-holding materials, there often occurs, according to their virulence, a more or less intense and extensive peritonitis. In particularly virulent, and also unpropitious conditions (where there are adhesions or the results of fornter light attacks, un suitable retention, etc.) the wholc wall will be infected in a very short
time, and then the symptoms of an inflammation are evident, sometimes with slight exudation or with great quantities of fluid, and it is then that sepsis of the peritoneum develops, which may prove fatal. In other cases there is a circumscribed inflammation which either heals, in spite of the impression it causes clinically as a large tumor, without any pus or with the formation of only trifling and quickly reabsorbed pus masses; or the inflammation may progress to the so-called perityph litic abscess.
The abscess 'IRS a location varying according to the position of the processus vermiformis, and the ensuing 'perforation usually occurs at the distal end, either in the lesser pelvis or on the lower part of the ilium. From here it spreads toward the place of least resistance, in the lesser pelvis, and passing the lowest portion of the same, it ascends on the lefts side, along the rectum. If it does not enlarge, it can of itself often sink into the lesser pelvis, following the law of gravitation, and from here can rise on the left side, along the rectum. This abscess may burrow. Only in rare cases will the retroceeal pOSitiOn of the appendix in the lumbar region rte met with. With a rapid increase of exudates, which is not a rare process in children, the above-mentioned manner of burrow ing is not observed. The abscess here encounters no boundaries and soon fills a great part of the lower abdomen.
of the stomach and intestine frequently cause affections of the appendix in children, It is indifferent whether they are accompanied by constipation or by diarrhma. In children we almost always find some portion of the appendix affected, chiefly in infections of the large intestine (Selter, Boas). This disease both shares in, and is classed with, practically all of those having follicular elements, for the reason that the appendix has the same anatomical structure and is of remarkable size.
It proceeds from inflammatory conditions in the cecum, conjointly, with tonsillitis; it is also observed in infectious diseases, especially in large epidemic outbreaks (Sahli, Sonnenburg).
The earlier opinions which considered that a seybalous stone in great part the cause of appendicitis and periappendieitis certainly do not hold now. The scybalous stone generally arises as a secondary factor and is etiologically of no account. Just as foreign bodies are actually drawn in—by children very frequently—they play only a secondary part in the perforation through pressure on the diseased wall of the appendix.
The same etiological importance has of late been frequently given to intestinal worms and their eggs (dlenvers, Schiller). Trauma leads also, not directly but only where there exists an already diseased ap pendix, to perforation, torsion, or the equivalent (Sonnenberg, Payr).
There is found chiefly a mixture of various species of bacteria, with a prevailing share of the colon bacillus. Yet pure infections also, appear ("Kokkenperityphlitis," Lang).