A. Chronic, recurring.
B. Chronic, much thickened.
C. Acute, with necrosis and rupture.
D. Showing necrosis of mucous membrane.
E. Gangrene and perforation, permitting fecal extravasation.
F. Total gangrene without perforation.
Appendicular Colic.
—Sufficient has been said above regarding the appendix as a miniature intestine, its outlet guarded by the little valve of Gerlach, to afford an anatomical reason why conditions even in the larger bowel should be imitated here. Some writers have not placed as much stress upon appendicular colic as I would here. One sees many instances of it if he will only recognize it, the frequency of its occurrence not only disturbing the comfort of patients, but keeping ever before their minds the necessity for operation. An absolutely empty appendix will be free from all abnormal activity of this kind, but when a little fecal matter has become imprisoned, and when by its long retention fecal concretions have formed, they may give rise to considerable disturbance without actually producing inflammation, the former being due to the spontaneous effort of the appendix to expel them. This effort may be excited by other conditions in the bowel adjoining, but by itself it may be the essentially relatively violent muscular effort which produces pain and is followed by soreness. That not a few cases of acute appendicitis commence with an appendicular colic is extremely probable, and that it may occur at frequent intervals and never pass the colicky stage is equally true. Appendicular colic, then, may be a precursor of an infectious appendicitis, acting as a predisposing cause, or either may occur independently of the other.
Indications of this form of colic are frequent, viz., nagging pains in the region of the cecum, which may last a few moments or a few hours and then subside, leaving a tenderness which persists for a day or two, after which the patient seems to be free for a longer or shorter interval, to suffer again and again in the same way. These attacks may be accompanied by some nausea, will be found frequently associated with whatever may have disturbed ordinary intestinal activity, and may even produce a mild degree of fever, which latter is partly due to mental perturbation and partly to a mild degree of toxemia, the latter being possible in connection with abnormal appendicular activity, as the appendix itself is a closed sac and the very materials which it is trying to expel may furnish the toxins.
It is difficult to distinguish between appendicular colic and mild attacks of catarrhal appendicitis. The transitory nature of the former is its particular diagnostic feature, coupled with absence of all lasting indications.
The following would seem the simplest working classification of lesions of the appendix.
| A. Acute. | - | Catarrhal. | Endo-appendicitis. | ||||||
| Diffuse. | Parietal or interstitial. | - | Hyperplastic. | ||||||
| Obliterative. | |||||||||
| Purulent. | - | Intertubular. | |||||||
| Intramural. | |||||||||
| Peri-appendicular. | |||||||||
| Any of these may lead to | |||||||||
| Gangrenous or | |||||||||
| Perforative lesions. | |||||||||
| B. Subacute. | Recurrent or relapsing. | ||||||||
| C. Adhesive or obliterative. | |||||||||
Almost any of the above forms may be associated with diseases of other abdominal viscera, as, for example, with typhoid. Thus out of 119 autopsies on typhoid patients 19 showed changes in the appendix corresponding to those produced by the typhoid organisms in other portions of the intestines. (Kelly.) Of 3770 autopsies on tuberculous patients tuberculous lesions were noted in the appendix in 44 instances. The appendix may also become involved with any form of ileocolitis, either in the young or in the adult. Again an infection of the right tube and ovary may easily extend to and involve the appendix, just as infection may travel in the opposite direction. (See [Plate LI].)
Before discussing the causes of this condition it is advisable to take a comprehensive view of the entire subject in its pathological relations. As Dieulafoy has shown, appendicitis is the consequence of the transformation of the hollow conduit into a closed cavity, whose length and narrowness make it liable to such changes, for which various causes are to be assigned: for example, the formation of calculi or concretions which are quite comparable to renal or biliary and which lead to a true appendicular lithiasis. There is even reason to believe that a calculous appendicitis may be hereditary and belong to the patrimony of gout. At other times it is the consequence of local infection, followed by tumefaction, and corresponding to obstruction of the Eustachian or the Fallopian tubes. Again it results from slow, progressive fibrous alterations or from the strangulations due to twisting or formation of adhesions. In any event the closed cavity varies in size and shape, and does not necessarily lead to self-destruction unless the bacteria thus pent up are sufficiently virulent. At all events the attack declares itself only when the cavity is actually closed, and it is then that imprisoned bacteria, previously harmless, multiply and intensify their virulence, as they do in a blocked loop of bowel. At times an acute intoxication from toxins is produced, and may be so pronounced that patients succumb to it almost before the characteristic lesions, or any local peritonitis, has become fairly outlined. On the other hand if retained bacteria be but slightly virulent, or have been successfully conquered by phagocytes, or if the canal has become pervious again, the attack may spontaneously subside, although there is great probability of recurrence. In many instances the infection ends in ulceration, abscess, gangrene or perforation, all of which may give rise to peritonitis of varying extent and severity. Germs may traverse the walls of an affected appendix without perforation. It may then become the direct cause of peritonitis, septicemia, or hepatic abscess.