scess forms in the peritoneal cavity in the region of
the appendix, but if already inflammation has happily glued the
intestines together around that area, the pus is confined within
definite limits. But as the abscess increases in size the demand for its
evacuation becomes urgent. The pus, under the influence of a natural
law, seeks its escape by the path of least resistance; sometimes this is
into the intestine, and occasionally into the bladder. The most
satisfactory course which it can take is through the wall of the abdomen
and out above the right groin. As it is making its way in this direction
the skin over that part becomes red, swollen, hot and tender, and the
tissues between it and the skin become swollen and brawny. Rarely is
_fluctuation_ to be made out until the pus has worked its way close to
the surface. Later, ulceration takes place in the undermined skin, and
the stinking contents of the abscess escape, greatly to the relief of
the patient. But long before this could happen the surgeon should have
made an incision through the inflamed tissues in order to give nature
some greatly needed help. For in many cases she allows the pus blindly
to discover that the course of least resistance is not towards the
surface of the abdomen but through the inflammatory barrier formed by
the adherent coils of bowel, and so into the general peritoneal cavity.
This unfortunate issue may give temporary relief to the patient, so that
he says that he feels much better, and that his pain has nearly gone.
But though his temperature may fall, his pulse is apt to quicken--an
ominous coupling of symptoms; the paralysed bowels become further
distended, so that the lungs are pressed upon and breathing is
embarrassed; hiccough comes on; and whether operation is now resorted to
or not, a fatal end is highly probable. In other cases, the escaping pus
finds its way up towards the liver and forms an abscess below the base
of the lungs.

If operation is performed when appendicitis has run on to the formation
of abscess, and the diseased appendix presents itself, it should of
course be removed; but if it does not present itself the surgeon should
abstain from making a determined search for it, as in so doing he may
break down the barrier which nature has provided, and thus himself
become the means of spreading a septic peritonitis. Nor should he
attempt to make clean the foul abscess cavity. All that he should do is
to provide for efficien