APOPLECTIC STROKE.—See BRAIN, APOPLEXY or.
APPENDICITIS,—Inflammation of he vermiform appendix. At the very tip of the cmcum, or blind pouch, situated at the beginning of the large intestine, there is located an organ which closely re.Fembles in form and size an ordinary earthworm, and which is known as the vermiform appendix (sec Fig. 73). Inflammation of this organ is quite frequent, and gives rise to the disease known as appendicitis. The appendix is located in the lower portion of the abdomen on the right side. Its cavity is in the form of a narrow canal, and constitutes a favourite site for the deposit of bits of faecal matter, which may become hardened and form the so-called " faecal concre tions " (see Plate MIL, Figs. 3, -t), and also of bacteria of various kinds.
Occasionally foreign bodies, such as fragments of hone and fruit-pips, find their way into its lumen, and a warning should therefore be extended against accidentally swallowing these. The irritation resulting from the presence of this foreign material produces an inflammation of the mucous membrane, which becomes red and swollen ; and the condition is accompanied by fever, pain, and often nausea and vomiting. This is the most frequent and the simplest type of inflammation, and also apt to produce the least harm. It may come on suddenly in the midst of perfect health, or it may follow some indiscretion in diet, or long-continued constipation. If the disease runs an uncomplicated course, the initial violent symptoms disappear within three or four days. But if the fever remains high and the pulse rapid, then one has to deal with complications which are usually serious in character.
The ordinary type of catarrhal appendicitis may subside under medical treatment alone. The patient should remain in bed, on his hack, and keep as quiet as possible. The diet should be exclusively fluid—milk, and soups ; small pieces of ice may be swallowed, and an ice-bag kept over the lower right portion of the abdomen. The medical treatment aims to relieve the pain and keep the intestines quiet, in order that the inflammatory process may not extend. After the disappearance of the fever, the patient should he kept in bed for at least another eight days under careful diet. Appendi citis belongs to that class of diseases in which recurrences are likely, and these are usually worse than the initial attack.
The second type of this disease is the purulent. This develops from the simple form just described, and sometimes on the first day. The suppura tive process extends from the mucous membrane to the muscular Avail of the appendix and then rapidly invades the peritoneum, from which results a circumscribed peritonitis. It is the generalisation of the latter which
causes the great danger in appendicitis. At first the purulent focus may not be larger than a hazel-nut, and separated from its surroundings by newly-formed inflammatory adhesions, which prevent the rupture and con sequent spreading of the pus through the general peritoneal cavity. The more extensive the abscess, and the longer it is present, the greater the danger of a general peritonitis. It is essential, therefore, to provide as soon as possible for an evacuation of this focus of infection. This can he accom plished only by the knife of the surgeon, as the absorption or evacuation of the pus through the medium of the gut is so rare an occurrence that no reliance should he placed thereon. If the rupture of the abscess into the free peritoneal cavity occurs, the latter becomes filled with the pus, and surgical interference is too late to do much good. For this reason every case of appendicitis needs careful watching by the physician from the very beginning, as a change for the worse may take place at any time.
The third form of appendicitis is the gangrenous, and this is the most dangerous. Perforation of the gangrenous tip of the appendix may take place during the first day of the disease ; the patient rapidly gets worse, the condition ending fatally within two or three days. The severe symptoms which accompany this type of the trouble are continued high fever, severe vomiting, marked abdominal distension, come, etc.
Unfortunately it is not always possible to determine just what form of inflammation is present in the appendix, nor what course the disease will take. For these reasons many surgeons claim that every case of appen dicitis should be operated for at the first evidences of trouble. This extreme view, however, is not universally adopted because careful statistics have shown that at least 75 per cent. of all patients with appendicitis get well after the first attack. Recurrences of the attacks, which may come on during succeeding years, make the prognosis for complete cure somewhat more unfavourable, because small foci of pus or adhesions to surrounding structures may remain. In such cases, the patient may well be advised to have an operation performed during the interval between the attacks \ neither pain nor fever is present. The operation is then less dangerous and the results more certain, especially if the appendix, which is the reuse of all the trouble, is entirely removed. This organ may readily be spared by the body, as it possesses no known value.