ACUTE INFLAMMATIONS 81 



enter the appendix,"'^ and owing to the stenosis of the 

 lumen the fluid parts escape more easily, and the 

 hardish residue is kneaded into a concretion in which 

 lime salts may be deposited. Eventually, the concre- 

 tion may lead to ulceration and an acute attack. Ad- 

 hesions of the actual vermiform process and cicatrisa- 

 tion of the meso-appendix leading to real kinking, tend 

 to a recurrence of the inflammation, but are themselves 

 the result and not the cause of the initial attack. 



A traumatic causation must be admitted in a few 

 cases. Either direct violence, as from a blow, or in- 

 direct violence, as from a strain, such as has been met 

 with in bowling at cricket, has on rare occasions been 

 succeeded by an attack of appendicitis. Often the in- 

 jury merely lights up old trouble by breaking down 

 adhesions. 



The histories of the vast majority of appendicitis cases 

 leave us, however, in doubt a§ to the actual exciting 

 cause. 



I remember once being shown an appendix (removed 

 at operation from a very early case) which showed an 

 intramural abscess. Kelly, in his standard work, 

 figures a specimen of acute catarrhal appendicitis show- 

 ing numerous minute ulcers, each corresponding to a 

 lymph follicle.! An appendix, the seat of early catarrh, 

 may show enlargement of the lymph-follicles without 

 any appearnce of ulceration. I have sections of most 

 acute early appendicitis which fail to show under the 

 microscope any lesion of the mucous membrane, though 

 numbers of polymorphonuclear leucocytes were visible 



* Some have erroneously supposed that the vermiform process 

 contains mucus only. If this organ be examined after death it will 

 •be found that the mucus is always stained with stercobilin, and that 

 the lumen often contains one or more boluses of faecal material, the 

 colour and bulk of which may even be visible through the intact wall. 



t " Plate I., Fig. 1. — Acute appendicitis with superficial ulceration 

 .... with the hand-lens the ulcers are found to occupy the centre 

 of a system of Lieberkuhn's crypts and correspond to the normal 

 position of lymph nodes." 



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