OPERATIVE TECIINIQUE.—inCiSiOn.— The incision that is generally preferred at present is that recommended by Mc Burney (see b, colored plate). It crosses an imaginary line (a) drawn from the anterior superior spine of the ilium (D) to the umbilicus (A) at the juncture of its middle and lower thirds, and thus overlying the diseased structures. The integument and a ponenrotic structures are alone to be incised, the muscular fibres being separated by means of the scalpel-handle in a line parallel to their course. As a result, muscular action will rather tend to approximate than to draw apart the edges of the wound and thus prevent post-operative hernia: a condi tion frequently met with, especially when the median incision was generally used. The latter is still resorted to by some surgeons, and is especially useful when diffuse abscess is present.
The lateral incision is preferred, be cause (1) it lies directly over the route of the appendix: (2) it exposes the field of operation more favorably than the median; (3) it creates a shorter. a less exposed, line of drainage. The advan tapes of the median incision are: (1) greater probability of not encountering adhesions between the anterior wall and the intestines in the line of incision; (2) easier access to all parts of the peritoneal cavity for washing and for drainage. Joseph Price (Buffalo Med. and Surg. Jour., Dec., '91).
The frequency of post-operative her nia has caused surgeons to greatly reduce the length of incisions, and Morris has shown that an opening through the mus cular tissues inches in length was sufficient in the majority of instances. McBurney has found that even in his method the opening in the deeper layers of the abdominal wall need not be more than two inches in length.
Probably few appreciate the number of cases of hernia following this opera tion. Since April, 1895, there have been observed at the Hospital for the Rupt ured and Crippled fifty-five cases. There was evidence that in many instances the wound was improperly closed. Per haps in a large majority of the cases there had evidently been suppuration during the healing of the wound. Coley
(Annals of Surg., Aug., '97).
Surgeons are now using a much smaller incision than formerly in order that they may avoid post-operative hernia, which is due to the fact that the lines of muscle-traction at this point are different in the different muscles. A pad over the seat of operation induces hernia by causing absorption of the new connective tissue as it is being formed. The margin of each muscle should be separated with the greatest care when operating; likewise care should be taken in dividing the peri toneum. In closing the wound each different layer of muscular tissue as well as the peritoneum and fascia should be united with the same tissue from which it was separated in the beginning. Thus the lines of muscular traction will not be disturbed, and hernia is less likely to he produced. No bandage or pad should be applied. The patient should be kept in bed for at least twenty-five days following the operation. r, . T.
Morris (Southern Practitioner, Nov., '97).
McBurney recommended his method only for non-suppurative cases or those in which drainage was not required, but many surgeons employ it with advan tage in almost all cases of appendicitis, including those in which an abscess is present and where drainage is required.
Three illustrative eases. In all, the abdomen had been opened by splitting the aponeurosis of the external oblique, separating the fibres of the underlying muscles, and dividing the fascia and peritoneum transversely. After having removed the appendix and the pus, and inserted gauze and rubber drains, the opening was narrowed by catgut su tures in the different layers, leaving a hole not more than an inch in diameter, which proved ample for drainage. In cases in which the opening proved too small to permit of the necessary manipu lation within the abdomen, it could be enlarged by cutting at right angles to the deeper part of the incision along the border of the reetus; this secondary incision could then be closed by suture, and drainage made through the pri mary portion as in other cases. Stimson (Annals of Surg., Mar., '97).