THE VERMIFORM APPENDIX. 33 



2. Just distal to this there is a considerable dilatation of the 

 lumen for a distance of from 7 to 8 millimeters. This area 

 shows some thickening of the wall of the appendix on the mesen- 

 teric side, the thickening being accounted for chiefly by an 

 increase of the fibrous elements of the submucosa along with 

 some muscular hypertrophy and slight increase of the subperi- 

 toneal fibrous tissue. The mucosa here has largely disappeared, 

 and in places the fibrous submucosa shows a myxomatous 

 degeneration. 



On the side opposite the mesentery, however, the wall is 

 much thinner, and it is from this portion that the cyst has 

 arisen. From within outward, the mucosa is largely destroyed, 

 the submucosa fibrous, the muscularis is much atrophied, and 

 one portion of the subperitoneal fibrous tissue is slightly thick- 

 ened. At one point the mucosa, submucosa, muscularis, and 

 a portion of the subperitoneal fibrous tissue have undergone 

 a solution of continuity, and the cyst has formed as a hernial 

 protrusion of the peritoneum, lined internally by a thin part 

 of the outer layer of subperitoneal fibrous tissue. Direct con- 

 nection exists between the cyst and the lumen of the appendix 

 at this point, which is 15 millimeters from the base of the 

 appendix. The fibrous tissue lining this cyst has undergone 

 extensive myxomatous degeneration. 



3. Distal to this, the lumen of the appendix is reduced to 

 a minimum, the reduction being caused by a much thickened 

 and fibrous submucosa and muscularis encroaching upon the 

 lumen. Here the mucosa is represented by only an occasional 

 remnant of a glandular tubule. 



4. Beyond this the distal third of the appendix is dilated 

 and its walls are thin. Here remnants of mucosa retnain in 

 a state of mucoid degeneration with abundant round-celled 

 infiltration, the lymphoid elements of the submucosa are re- 

 placed by fibrous tissue, the muscularis is atrophied, and the 

 subperitoneal fibrous tissue is somewhat thickened. The ex- 

 treme apex is formed by a thin wall of fibrous tissue containing 

 only a few muscular bundles. 



The contents of the cyst and appendix are of a myxomatous 

 character, the white flakes mentioned corresponding to masses 

 of exfoliated epithelium and cells which have exuded from the 

 vessels. These masses do not take the form of definite glan- 

 dular structures, but in places do suggest that they are portions 

 of the mucosa which have become exfoliated. They are prob- 



