Area 2: Retro-cwcal.—Abscess is met in this area (see also Fig. 6) in about 23 per cent. of the eases. The appendix lies in the little pouch posterior to the cmcum, more or less curved or folded upon itself or extending downward and outward.
It is best opened by an oblique incision parallel to the outer half of Poupart's liga ment, coming down upon the outer border of the cmcum, which should be raised up and turned inward. The appendix can nearly always be removed, unless it should be too firmly imbedded in the exudate forming the inner wall.
Area 3: Supra-mcsenteric.—Abscesses here (see also Fig. 7) have a tendency to spread toward the liver and duodenum. The appendix lies above the mesentery of the ilium and in ternal to the inner layer of the mesocolon.
These abscesses are best reached by an in cision along the external border of the right rectus muscle, great care being taken not to break down the adhesions between the loop of small intestine to the inner side. (See in cision c in first colored plate.) Area 4: Exter-nal.—This is the space be tween the outer border of the colon, with its outer layer of mesoeolon, and the external abdominal wall. The appendix may extend upward and outward into this space, its tip sometimes reaching nearly to the under sur face of the liver. Abscesses spread to the liver and have repeatedly ruptured into the pleura and even into the bronchi.. (See Fig. S.) They may be reached by an oblique incision extending from above the crest of the ilium downward and inward, parallel to the outer third of Poupart's ligament; or. if the abscess is high up, by a longitudinal incision over its most prominent part, care being taken to not injure the ilio-hypogastric nerve. The appen dix can nearly always be removed, as there is no danger, in separating the adhesions about it, of opening the general cavity.
Area 5: Retro-eolonie, or Extra-peritoncal. —In the cellular space posterior to the colon between the two layers of the mesocolon. (See Fig. 9.) Abscesses here are entirely extra peritoneal. The colon is pushed forward.
The incision in these cases should be an oblique one, similar to the one described under the fourth area, but extending pretty well above the crest of the ilium. M. L. Harris
(Journal of the Amer. Med. Assoc., Dec. 21, '95).
In retrocmcal suppurative appendicitis an incision recommended along the ex ternal border of the sacro-lumbar mass of muscle, and extending forward at the lower extremity parallel to and at a distance of about an inch from the crest of the ilium to within a distance of about an inch and one-fourth from the antero-superior iliac spine. The signs of retrocmcal abscess are the following: Tenderness over the triangle of Petit; but little, if any, pain at MeBurney's point; marked fullness in the right flank; and a clear sound on pereussing the right iliac fossa. If the appendix be found on one side or in the front of the cmcum, it may still be readily ex posed by this incision. The situation of the wound permits perfect drainage and tends to secure the patient against the subsequent risk of hernia. Grinda (M6d. Mod., No. 71, '97).
Out of a total of GOO cases of appen dicitis (350 with abscess-formation) in Sonnenburg's hospital and private prac tice, the complication of subphrenic ab scess was met with in 9. In 6 of these the appendix and can= were displac0.1 beneath the liVer: so that the suppura tion passed directly into the subphrenic space, extraperitoneally in 1 case. intra peritoneally in the majority. Pyothorax was also present in 0 eases; there was dry pleurisy at the base of the lung and of the diaphragmatic pleura in 2 cases. The subphrenic abscess is easily opened and drained when it comes to the front below the costal margin; when it devel ops posteriorly, it must be approached by the transthoracic route. The rarity of subphrenic abscess in so large a num ber of cases of appendicitis is ascribed to the treatment of the latter by opera tion at a relatively early period of the disease. Korte has operated on 35 cases of subphrenic abscess, no less than 16 of which were the result of appendicitis. Weber (Centralb. f. Ofir., Mar. 10, 1900).