A Contribution to the Surgical Treatment of Diseases of the Appendix Vermiformis

two well-marked attacks of appendicitis, especially if the physical signs-more particularly a swelling in the situation of the appendix-persist in the quiescent period after the subsidence of the attacks.In two of the three patients operated upon after a second attack (Cases vi, vii) small collections of pus were found in the immediate neighbourhood of the appendix, while in the third patient (Case iii) the appendix was distended with fluid and upon the point of rupture.In another patient, operated upon after a third attack (Case iv), a hard faecal concretion was found in the appendix, probably the cause of the preceding attacks.When an appendix is constricted or occluded, and especially when it is distended with fluid or contains a faecal concretion, tllere is always a risk of ulcera- tion and perforation taking place, followed by escape of its contents and suppuration around it.Owing, however, to the fact that the appendix is under these conditions generally surrounded by adhesions, which act as a protective barrier, shutting off the general peritoneal cavity, this complication, as already mentioned, is usually followed by a local or encysted abscess, which may, however, sometimes form with acute symptoms, as in the following case. CASE IX.