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Every surgeon who treats patients suffering from acute appendicitis must be impressed with the fact that an unfavorable outcome in any given case means that the infection which was originally confined to the small space occupied by the vermiform appendix itself has first invaded the tissues immediately surrounding this organ and has then been distributed over the entire peritoneal cavity. In other words, in fatal cases the patient practically always dies as the result of a diffuse peritonitis.Other conditions may arise which may result in a fatal issue. There may be a septic thrombosis of the vessels in the vicinity of the appendix or an empyema, or even pyemia, but by far the greatest number of deaths occurs from diffuse peritonitis, and if it is possible to prevent this, the mortality from appendicitis must at once fall enormously. In order to plan a means for the prevention of this condition, it is well to study the progress of the disease from its onset.There is danger of the occurrence of diffuse peritonitis in the following classes of cases: 1, in gangrenous appendicitis; 2, in perforative appendicitis; 3, in cases in which the cecal end of the lumen of the appendix is closed and the distal portion so thoroughly distended with septic material as to make its walls permeable to micro-organisms; 4, in the very rare cases in which there are small abscesses in the walls of the appendix not directly connected with its lumen, and 5, in cases in which there is a septic thrombosis of some of the vessels, but not sufficient to cause gangrene.The first, second and third conditions are so common that every surgeon who operates frequently during the acute attack has seen them many times.Were it possible to keep the septic material in these cases within the circumscribed area in which it occurs primarily, it is plain that the condition would remain comparatively harmless.The appendix is virtually surrounded on all sides excepting in the direction of the median line by relatively fixed tissues. Above we find the lower end of the cecum and the cecal end of the ileum; to the right and in front is the parietal peritoneum ; behind the peritoneum covering the iliaeus muscle, and toward the median line it is surrounded by loops of small intestines. Moreover, the omentum extends far beyond its lower end.It is true that the appendix may be displaced downward, but in this case it will again be surrounded by fixed tissues which seem especially adapted to dispose of septic material. Again in this case there is an enteroptosis affecting the cecum, and always with this a marked lowering of the transverse colon and stomach and with these the omentum.Thus we see that the natural anatomical arrangement for the protection of the general peritoneal cavity is extremely efficient. There is but one weak point in the anatomical provision for this protection, namely, in the direction of the median line, because the great mobility of the small intestines naturally favors the distribution of septic material to all parts of the peritoneal cavity. ...