PRACTICAL CONSIDERATIONS: THE LARGE INTESTINE. 1685 



constipation which, when involving the caecum, may, by causing irritation and swell- 

 ing of mucous membrane, by encouragement of bacterial growth, by favoring the for- 

 mation of fecal concretions, by producing traction on the meso-appendix, or by direct 

 pressure upon the appendicular vessels, start the chain of pathological phenomena 

 which, beginning with hyperaemia, hypersecretion, and imperfect drainage, proceed 

 to distention, ulceration, perforation, or gangrene, with their associated degrees of 

 parietal or peritoneal infection. 



Constipation is present in the majority of cases of appendicitis (58 out of 69, 

 McCosh), and not only acts as a causative factor, but has a prejudicial effect on. the 

 result. In 22 cases of peritonitis from appendix disease occurring at the London 

 Hospital there were 9 cases of constipation, with 4 deaths, and 13 cases in which 

 the bowels were loose or easily moved, with 2 deaths. In another series of cases 

 (Richardson) there was 8 per cent, of constipation among those that recovered and 

 28 per cent, among those that died (White). No other important point of medical 

 treatment is in dispute and none has any anatomical bearing. 



Operation for appendicitis will, of course, vary with the seat and character of 

 the disease. 



1. The preferable method of access in removal of an appendix very early in an 

 attack, or during an interval, or when neither abscess nor extensive adhesions are 

 present, is as follows. The incision begins one inch above a line drawn from the 

 anterior superior spine to the umbilicus, and crosses that line one and a half inches 

 internal to the iliac spine. It should pass downward and inward and be about three 

 inches long. The skin and aponeurosis of the external oblique are divided in that 

 direction ; the internal oblique and transversalis fibres are separated in a direction 

 almost at right angles to the first incision ; the transversalis fascia and peritoneum 

 are divided on the same line with the internal oblique. 



The advantages of this incision are thus described by its originator. " Muscu- 

 lar and tendinous fibres are separated, but not divided, so that muscular action can- 

 not tend to draw the edges of the wound apart, but rather to actively approximate 

 them. Excepting during the incision of the skin, almost no bleeding occurs. The 

 fascia transversalis not being drawn away by the retraction of the deepest layer of 

 muscular fibres, this fascia is easily completely sutured, and thus greater strength of 

 repair is assured" (McBurney). 



More room may be obtained and the transverse severance of muscular or 

 fascial fibres still minimized by stripping the external oblique aponeurosis up to the 

 median line, dividing the anterior sheath of the rectus in the line of the separation 

 of the internal oblique and transversalis fibres, lifting up and retracting the rectus 

 towards the median. line, ligating the epigastric vessels (which will be seen lying on 

 the thin transversalis fascia over the peritoneum), and then extending the original 

 peritoneal incision as far inward as may be necessary (Weir). 



2. In later operations it is best to be guided by the situation of the tumor or 

 the area of tenderness or dulness, inclining to approach it from without inward. 

 An oblique incision well out towards the upper third of Poupart's ligament will be 

 less likely to open the general peritoneal cavity unnecessarily in cases of abscess, 

 and less likely to be followed by ventral hernia. In retroperitoneal abscess an 

 incision so placed will not infrequently open the abscess without going through the 

 peritoneum at all. 



3. In the presence of general purulent peritonitis a vertical incision on the 

 outer border of the rectus or a long median incision will best enable the appendix to 

 be dealt with and at the same time permit of the efficient cleansing and irrigation of 

 the peritoneal cavity and the introduction of drainage. 



4. After the peritoneal opening is made the appendix can often easily be found 

 and brought out of the wound. If this is not done readily, the colon should be 

 identified — the first portion of intestine found attached to the posterior wall as the 

 finger is passed along that wall inward from the incision — and the anterior muscular 

 band traced downward to the base of the appendix. 



The Colon and Sigmoid Flexure. — Like the other main subdivisions of 

 the intestinal tract, the colon is larger at its commencement than at its termination, 

 measuring on the average 8 cm. (3^ in.) in diameter at the caecum and 3.5 cm. 



