Like the bowel above, the appendix may suffer in various as well as in similar ways. Thus in it may be seen pathological conditions which involve the bowel proper. Tuberculosis and actinomycosis may even occur here as apparently primary lesions, while cysts have been discovered within its walls, and such tumors as fibromyomas or primary adenocarcinomas are also met here. I have seen three or four instances of primary cancer of the appendix, and have now living one patient from whom six years ago I removed an appendix and adjoining portion of the cecum involved in most distinct cancer.
Again, the appendix participates in certain hernias and has been found in instances of strangulated or non-strangulated inguinal and femoral hernia, and has been seen also in cases of umbilical hernia. Twice I have found it in the inguinal canal and once in the femoral.
Furthermore when diseased the appendix, like the bowel, may contract adhesions to certain viscera, while it is now well known that it may attach itself to the kidney, the bladder, the right ovary, the tubes, or the uterus. This is of more than mere passing interest, for by such adhesions cases are not only surgically complicated, but diagnosis is made difficult, because of associated symptoms pointing to the organ thus involved.
Foreign Bodies in the Appendix.
—Foreign bodies are occasionally found. This expression refers not merely to the fecal concretions above mentioned, which are practically small enteroliths. Thus, Kelly has mentioned cases in which ordinary pins have been found in this location, two of these cases being my own. In one instance I found the appendix to contain a round-worm at least three inches in length, and other intestinal parasites have been found by other observers. The laity have been greatly impressed by the reputed frequency with which grape and other seeds are found in the appendix, these figuring in their eyes as exciting causes of disease. In truth seeds are seldom found, that which has been mistaken for them being fecal concretions of various sizes and degrees of density. I have found actual seeds two or three times, but probably not oftener.
Bacteriology of Appendicitis.
—Acute appendicitis being essentially an acute infection one inquires naturally which are the organisms most commonly involved. Answer to this question should be sought rather in the text-books on pathology, and should be summarized here by simply saying that the colon bacillus is perhaps more often found in connection with these cases than any other one organism. Streptococci and staphylococci rank perhaps next in frequency, while the pneumococcus, the capsule coccus, and all of the other pyogenic forms may be present, either as contaminations or in almost pure cultures. The fauna and flora of the intestinal tract afford ample opportunities for contaminations with many forms of microbes. If pus found here be a pure culture of any one organism it is most often of the colon variety, which is known to vary much in virulence, even when occurring alone. Mixed infections, however, are more predominant and more serious, especially in proportion as the more active pyogenic organisms appear in greater numbers. The bacteriology of appendicitis is then of great pathological interest, but concerns the surgeon very slightly, unless he have to do with some peculiar form, such as pyocyaneus, or a particularly virulent streptococcus.
PLATE LI
Illustrating Various Degrees of Involvement of Appendix Vermiformis. (Richardson.)