i68 4 HUMAN ANATOMY. 



Results and Complications of Appendicitis. A cursory review of the anatomical 

 relations of the appendix, considered in conjunction with the pathological varieties 

 of appendicitis, will explain the varying results of this disease. The appendix is 

 entirely intraperitoneal in its situation and becomes primarily the focus of intraperito- 

 neal lesions, although in certain cases (vide infra), from pathological changes, it and 

 the associated exudate or abscess may be either practically or really extraperitoneal. 

 That focus may be isolated by adhesions between the peritoneal coverings of the 

 neighboring structures the coils of small intestine, the caecum or colon, the parietes 

 or may become the starting-point of a general septic peritonitis. In the former case 

 the usual local symptoms of inflammation or of abscess will follow according to the be- 

 havior of the exudate, which may remain plastic or may liquefy and become purulent. 

 In the latter case, to the above-mentioned symptoms which are much intensified, as 

 a rule are added general rigidity from involvement of larger areas of the abdominal 

 wall, distention and tympany from paresis of the small intestine (page 1756), and from 

 the same cause obstinate vomiting and more or less complete intestinal obstruction. 



The acuteness of the attack, the presence or absence of gross perforation or 

 gangrene, and the anatomical position of the individual appendix will often determine 

 the localization or diffusion of the septic infection. 



The usual anatomical situations of appendix abscess may be summarized as fol- 

 lows, (i) Anterior, the caecum forming the posterior wall, agglutinated coils of 

 intestines the inner wall, and after the abscess has attained some size the parietal 

 peritoneum the anterior wall. (2) Posterior, the hinder surface of the caecum 

 forming the anterior wall, especially if the appendix is post-caecal in position, or if a 

 septic lymphangitis has extended backward between the layers of the meso-appendix. 

 Such an abscess is extraperitoneal, and may originate in an appendix which, it is 

 believed by some, was ab initio either wholly or partly extraperitoneal (4 per cent. , 

 Bryant), or, as seems more probable, had become so through pathological causes 

 (38 per cent., Ferguson, page 1666). The abscess is limited by the fascia transver- 

 salis anteriorly and the fascia iliaca posteriorly, and by their, fusion at Poupart's liga- 

 ment inferiorly, although rarely it may follow the femoral vessels downward and 

 appear on the thigh, or may perforate the parietes above the outer third of Poupart's 

 ligament, or may make its way into the peritoneal cavity, or into the pelvis, escaping 

 through the obturator or the sacro-sciatic foramen. It may ascend (following some- 

 times the retro-colic fossa, page 1667) to the perinephric or even to the subphrenic 

 region. (3) Inner, the inner surface of the colon and caecum and the mesocolon 

 bounding it postero-externally and adherent coils of small intestine antero-internally. 

 If the parietal peritoneum does not form part of the anterior wall of such an ab- 

 scess, the general peritoneal cavity must be traversed in reaching and evacuating 

 it. (4) Inferior, the abscess occupying part of the pelvic cavity with agglutinated 

 intestinal coils bounding it superiorly. 



All these abscesses may perforate into the cavity of the peritoneum, but sponta- 

 neous opening into the caecum, colon, rectum, small intestine, bladder, or on the sur- 

 face of the body has frequently occurred ( Finkelstein, quoted by Mynter). The various 

 symptoms which may result from the propinquity of the abscess to other structures 

 should be worked out anatomically, e.g. , (i) cedemaoi the abdominal wall over the 

 abscess ; (2) flexion of the thigh, extension of which is painful from involvement 

 of the ilio-psoas ; or marked lumbar tenderness (perinephric) ; or immobility of the 

 right lower thorax (subphrenic) ; (3) tympany over an ill-defined swelling, from in- 

 t(T]>i>sitii)M of coils of small intestine between the abscess and the parietes (although 

 this may be simulated by the escape of intestinal gases through a gross perforation 

 into the cavity of an abscess of any type) ; or (4) vesical or rectal irritation. 



Anatomical /\>ints rc/aling to the Treatment of Appendicitis. The medical 

 treatment of this disease is of anatomical interest only in its relation to the possibility 

 of removing the mechanical causes and favoring either resolution or localizing adhe- 

 sions. Opium for the purpose of lessening peristalsis and thus permitting omcntal 

 and intestinal adhesions to wall off the appendix has still some advocates, especially 

 when combined with gastric lavage and exclusive rectal alimentation (Ochsner). 

 Hut the received views as to etiology (ride supm} and clinical experience are both 

 overwhelmingly in favor of purgation and starvation as preventing or removing the 



