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the possibility of, more correctly speaking the probability of, general infection, a grave prognosis was made, his relatives being told that the chances for recovery were much against him. To our surprise and gratification, the patient's recovery was unusually rapid and uneventful; there being no temperature, abdominal distension or discomfort, save that resulting from the dressings becoming saturated with pus and fecal matter, which necessitated frequent changing. The fecal discharge remained about the same until the fourth day, when it began to rapidly diminish, and by the tenth day had entirely ceased. Patient left hospital four weeks after operation, and could have gone much sooner, but he wished to return to his home, some few hundred miles distant, hence the delay. A slight fistulous opening from the abdominal wall persisted for some time, but closed some five weeks after the patient left the hospital.

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H. B. DECHERD, M. A., M. D.,

Demonstrator of Anatomy, University of Texas.

So many, indeed, are the logical anatomical reasons why appendicitis should be a common affection that those who have given the matter much study are very apt to wonder why it does not occur even more often than it does.

In the first place, comparative anatomy shows that the appendix vermiformis of man is the relic of a very large cæcum in some of the lower animals; and it is a matter of common knowledge that organs or tissues which are retrograde remnants instead of advancements have little resistance, and are prone to become diseased on the least provocation.

Secondly, take a glance at the lumen, and note that it is quite small, even in proportion to the size of the organ; hence drainage into the cæcum (of the utmost importance normally, but in diseased conditions especially) is not of the most perfect kind. Furthermore, where inflammation is present, the drainage will be still less, because the lumen becomes still smaller. Add to this the fact that constrictions are very apt to occur in different portions of the canal, and we have even a worse condition still from the standpoint of drainage.

A third factor, and one to which special attention must be called, is the great amount of lymphoid tissue which is found in the appendix. This form of tissue occurs to some extent in other parts of the intestinal tract, but not by any means to the extent noted here. Indeed, its presence here might be compared to that found in the tonsil (faucial). Wherever it becomes necessary to protect the system against the invasion of foreign particles, disease germs for



example, nature has met the emergency by providing lymphoid tissue as a barrier. This is usually in the form of lymphatic glands, but may be specialized as in the tonsil and appendix. On account

. of its exposed situation, probably more than on account of any special proneness to inflammation, this lymphoid tissue often becomes the seat of inflammatory and ulcerative processes; and, under these circumstances, it manifests a capacity to increase in size in a very short period of time, bringing about a condition of great swelling, which, however, may disappear just as quickly as it was formed. Thus, no doubt, can be explained the frequent cases of severe tonsilitis. These are manifested by marked rise in temperature, embarrassed breathing from enlargement of the tonsils, great pain on the least attempt to swallow, and a large, red tumor mass projecting from each side of the fauces, and which may be covered by à cheesy or membranous exudate. These symptoms may be so acute that the patient takes to his bed, and refuses all food for two or three days on account of the pain of swallowing. But just as definite and rapid as the oncome of this condition of affairs is the rapid and complete return to a state of normality. For, indeed, in

. only a few days the picture may be quite different-no fever, no

pain on swallowing, but pulse natural, swelling and redness of tonsil gone, and patient comfortable. Compare with this the similar features of acute appendicitis with the rapid rise of temperature, severe pain, which may or may not become localized, and the marked constitutional disturbance as in tonsilitis. Here again, after such symptoms of danger have passed, if the appendix be exposed by incision, the surgeon is very likely to find not an inflammatory mass of adhesions and a large red appendix, but, in a large class of cases, a very normal and inoffensive looking little organ. What has happened here, and analogously also in the tonsil, is that the swelling of lymphoid tissue has subsided, and in consequence (in the case of the appendix) the circulation, which had been impaired because the lymphoid tissue was tightly bound by the peritoneal coat, has greatly improved, the lumen is restored once more, and good drainage is insured. (See plates for distribution of lymphoid tissue.)

Another anatomical feature that undoubtedly bears on the etiology of the disease is the arterial distribution. The appendix is mainly nourished by a single artery, which runs in the free edge



of the meso-appendix. This is a branch of the ileo-colic artery, and when the mesentery of the organ is lacking, as it sometimes is, it courses under the peritoneal coat. This vessel has no important anastomoses, or is, in other words, a terminal artery. Especially is this the case towards the free end of the organ, the situation where necrosis, sloughing and gangrene are most apt to occur. As shown in the accompanying plates, the number of vessels is large, and these are quite widely distributed; it is the fact of terminal arterial circulation that is responsible, for if collateral trunks were present the appendix could the more easily combat inflammatory tendencies.

Finally, disease germs (streptococci, colon bacilli, etc.) are always on hand, as well as foreign bodies (fecal concretions usually, but occasionally seeds, particles of metal and the like), and in a mucosa and submucosa that are so prone to undergo progressive degenerative changes, the above irritants are provided with just the proper pabulum for establishing an inflammatory process.

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Fig. 1. Showing cæcum (a), ileum (b), appendix (c), meso-appendix (d), artery to appendix (e),

anterior longitudinal muscular band of cæcum (f), ileo-colic artery (g). Points of surgical interest are that the artery to the appendix runs in the free edge of the meso-appendix; and the three longitudinal muscle bands of the cæcum will always lead to the vermiform appendix. Only the anterior band seen here.

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FIG. 2. Showing minute structure of the average dissecting-room appendix. The lymphoid tissue (b) no doubt shows some hypertrophy. Its arrangement in the form of nodules can be noted. At the lumen (a), are seen Lieberkuehn's glands (c), encroached upon by the overgrowth of lymphoid tissue (b), and somewhat disrupted. Mucosa (d), submucosa (e), blood vessel (f), fat (g), circular muscle (h), longitudinal muscle (i), peritoneal coat (j).

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