exception, were of the acute suppurative form, and all received medical treatment for a period of from two to twenty days.

Number of cases treated without operation: males, 9: females, 8; total, 17. Deaths: males, 2; females, 7; total, 9. Cause of death septic peritonitis, 4; rupture of abscess into abdominal cavity, 4; unknown, 1. Of the eight cases recovering without operation, two were operated on during subsequent attacks; one has not had any recurrence; four have had several slight attacks of pain and tenderness in the right iliac region; and one case, occurring last May, is in good condition August 15, 1897.

THE OPERATION ITSELF IN APPENDICITIS.

BY LEWIS S. MCMURTRY, M.D.,

LOUISVILLE.

HITHERTO our discussions upon appendicitis have been directed for the most part to the pathologic condition as related to symptomatology, with a view to early diagnosis and determination of the question of operative interference, with only brief and incidental consideration of the operative technique. The multifarious types presented by the disease, the variety in character and extent of the lesions, the several stages of progress in which operation is performed, the complications and sequela, compose a series of requirements in operating which may only be successfully met by the best surgical judgment and operative skill. In veiw of these facts, and the additional one that the profession has very generally come to recognize appendicitis as a strictly surgical disease, cured only by operation, I have selected the operation itself as an appropriate and profitable theme for discussion at this time.

I propose to consider the subject under the following heads: (1) The incision. (2) Dealing with adhesions and with abscesses. (3) Removal of the appendix. (4) Drainage and isolation of the peritoneum by gauze.

THE INCISION. Concerning the incision, three important considerations must be observed, the first being to obtain easy access to the caput coli, with sufficient working space; the second, to secure all natural advantages to facilitate drainage; and the third, to secure complete repair of the parietal structures incised and thereby prevent the occurrence of hernia.

The early operations for appendicitis were mostly undertaken in extreme cases, in which suppuration had occurred, and consisted in cutting into the abscess and evacuating and draining the same. For this purpose the vertical incision was adopted and is yet practised by many surgeons. This incision is made along the external border of the right rectus muscle, a little to the inner side of the

right semilunar line. It should intersect a line drawn from the anterior-superior iliac spine to the umbilicus, very nearly midway, and should be about three inches long. The sheath of the rectus had best be pushed aside slightly and not opened, so as to lessen the amount of bleeding. The muscles and fascia having been divided, the peritoneum is opened, and the caput coli found immediately beneath by the exploring finger. Kocher has called attention to the fact that a branch of the iliohypogastric nerve, which enters the sheath of the rectus, is divided by this incision. Atrophy of that part of the muscle supplied by this nerve has been observed after the operation. This incision furnishes good access to the parts involved; and when made and sutured under the protection of thorough asepsis, with proper management afterward, restores the integrity of the abdominal wall. In my early operations performed in this way, comprising a series of twenty-seven cases, mostly in the suppurative stage of the disease, the results were quite satisfactory. So far as I am aware, not one hernia occurred in the entire series.

The vertical incision does not, however, give as easy access to the appendix and to the outer and posterior areas adjacent thereto (which are so frequently involved) as does the oblique incision. The latter is preferable also for drainage, and affords an additional advantage by diminishing the danger of breaking through the inner wall when an abscess-cavity has formed about the appendix. This incision is made parallel with Poupart's ligament and traverses the line from the anterior-superior iliac spine to the umbilicus well over to the right side. It enables the operator to explore the right iliac fossa from the external boundary, thus giving protection to the general peritoneum which may already have been shut off by protecting adhesions. In my recent work I have operated altogether through this oblique incision.

A method of dividing the abdominal wall by a combination of incision and blunt dissection has been described by McBurney and commended by many writers on the surgery of the appendix. This is an oblique incision, in which, after dividing the skin and superficial fascia, the fibres of the parietal muscles are separated by a blunt instrument and held apart with retractors while the peritoneum is divided and the appendix removed. This incision is only applicable to non-suppurative cases, according to its author, though

some operators claim to have advantageously extended its application to those in which suppuration has taken place. The theory of this incision, of course, is that by tearing apart the bundles of fibres of the abdominal muscles, instead of dividing them by incision, the natural crossing of fibres in the muscular structure of the abdominal parietes is preserved, thereby preventing hernia as a post-operative sequel. These refinements are not practicable in cases of perforative appendicitis in which the life of the patient depends upon thoroughness of operation and free drainage. Moreover, it is doubtful if separating muscular structures with a blunt instrument yields any advantage over the division of those structures by incision, provided all proper care is bestowed upon closure and retention of divided parts by suturing. In grave cases of appendicitis, in which the patient's life hangs trembling in the balance, the incision should be made with a view to gaining access to the parts with sufficient working space and free drainage, other considerations being secondary.

In cases of recurrent appendicitis, in all cases in which there is no pus outside the appendix, and in all cases in which the requirements are properly met by a single drain, the utmost care should be bestowed upon the suturing of the incision. In these cases I have used the through-and-through suture with silkworm-gut, together with immediate suture of divided muscle and aponeurosis with interrupted sutures of catgut. In these non-suppurative cases the silkworm-gut sutures should be allowed to remain for ten or twelve days. In suppurating cases, when extensive gauze packing and drainage prevent immediate closure of the incision, one angle of the wound should be brought together as far toward the middle of the incision as practicable, and the remaining sutures of silkwormgut left untied until they may be utilized. The latter are the cases in which hernia is so often a sequel to operation, and I do not see that any method of suture can overcome this danger. They are really cases in which the open treatment is an absolute necessity. Patients treated in this manner should be required to remain in bed much longer than is customary, until organization and consolidation of the new tissue formation uniting the incised parietes are complete. This will do more toward the prevention of hernia in this class of cases than any particular method of incision or partial closure of the same.

ADHESIONS AND ABSCESSES. In dealing with adhesions and abscesses the same general rules of surgical treatment should be observed in appendicitis as in similar conditions affecting other organs inclosed within the peritoneum. Whenever practicable, adhesions should be separated, abscesses emptied, disintegrated structures composing foci of infection removed, and cleansing and drainage secured by measures of assured efficiency. It is an established procedure in pelvic surgery to incise and drain accumulations of pus in exhausted subjects as an operation of expediency, looking to improved conditions for radical operation and permanent cure. In a limited proportion of cases, nature completes the cure after such an incomplete operation. The same methods and similar results obtain in the treatment of appendicitis. The function of surgery is to save life; the attainment of ideals should be altogether subordinate to this supreme indication of all surgical operations. This axiom is eminently applicable to the disease under consideration, and, at the same time, we must concede that incomplete operations do not, as a rule, beget cures. In all operations for appendicitis, in all stages and varieties of the disease, the appendix should be removed whenever the patient's condition will permit completion of the operation. I am aware that many excellent surgeons endorse and pursue the practice of evacuating an appendicular abscesscavity, affording drainage, and partially closing the incision, without any attempt to remove the appendix, and close the cecum at the point of sloughing. Though this may be the better practice for the occasional operator, it is far from safe to leave within the abdomen a perforated and sloughing appendix. While a certain proportion of these patients recover under an incomplete operation, the aggregate of results, including cases of fecal fistula and secondary operations, is not equal to that of completed operations. This conviction has not been formed from theory or by analogy. I have opened appendicular abscesses which have burrowed along the intermuscular planes to a point in the lumbar region and other remote points, and in numerous instances the patients have recovered after protracted convalescence. On the other hand, I can cite numerous instances in which this procedure has failed. Four years ago I operated on a young woman, aged twenty-four years, with suppurative appendicitis. Her condition was critical when first seen, and operation was promptly performed. On opening the peritoneum