The McBurney method employed dur ing the past year in all suppurative as well as non-suppurative eases. Without cutting muscular structures it is possible to separate the internal oblique and transversalis muscle fibres in an out ward direction, so as to make a large enough opening to approach any abscess cavity in the iliac fossa and perform necessary manipulation in suppurative cases, including ligation or treating the appendix as desired. In leaving an opening in the intermuscular space to permit drainage there was no trouble in subsequent healing of the wound. The natural tendency of the muscular fibres to draw together in the direction of their length approximated those which had been drawn out of their course, and per mitted them to resume their function. As a rule, after granulation the wound unites in a fine, linear sear, without stitching. Abbe (Annals of Surg., Aug., '97).
For the prevention of ventral hernia McBurney's niuscle-splitting incision recommended, even though pus be pres ent; most of the wound is sutured and provisional sutures are placed which can be tied later. The early removal of drainage is a matter of great importance, the gauze drain is replaced by a shorter drain of by a drain of rubber tissue folded on itself like a fan. The removal of the appendix is advised when possible. The patients are kept in bed three weeks, and at the end of this time firm union is usually obtained. G. Woolsey (Med. Record, Apr. 1, '99).
Some operators have found that when the appendix is in the normal position and is not difficult to bring out, Mc Burney's method is almost ideal; but when difficulties arise and the incision has to be enlarged, the necessarily con stant and hard retraction of the muscles is likely to injure the tissue and some times to cause suppuration. If it is nec essary to enlarge the wound, there results a ragged and complicated wound, not well adapted to drainage if pus is found. The position of McBurney's incision is also thought by some to render proper drainage difficult to obtain. Other in cisions are therefore resorted to.
The hypogastric incision (f) may be more or less near the spine of the ilium, beginning a little above the line drawn from the umbilicus to the spine of the ilium, or it may be made wholly below this line. At the outset it may be two inches in length, and subsequently be extended in either direction if necessary.
This incision affords the following advantages: Less danger of injuring the subjacent intestine, the ileum, and the caput soli; less tendency to prolapse of the omentum and the ileum; it "walls off" the general peritoneal cavity with facility and certainty; it affords ex cellent drainage at the time of the oper ation, as well as subsequently. An ab
scess can be opened on its outer aspect in such a way as to prevent infection of the peritoneal cavity: a point of much importance. A minimum of injury is done to the muscles and nerves, and repair has not been followed by ventral hernia. J. S. Wight (N. Y. Med. Jour., Oct. 24, '9G).
An incision proposed by Jalaguier and recently recommended by Kammerer is especially applicable to cases occurring in slim children. It is thought to pre vent post-operative hernia better than any other. The skin and the aponeurosis of the external oblique are incised at the outer border of the rectus (d), and the aponeurosis on the inner side of this in cision is then dissected for some distance from the anterior sheath of the muscle, and drawn toward the median line, ex posing the sheath. An incision (e) paral lel to the first is then made in the latter sheath about one-half inch to the inside of the border of the rectus, exposing the muscle. When the operation is finished, the deeper incision is closed and the rectus, permitted to slip in place, acts as protecting covering. Kammerer recom mends it for adults.
Modified incisions have also been pro posed by other surgeons, among which those of Elliott, Vischer, Willy Meyer, Fowler, and Weir may be mentioned.
To avoid the drawbacks of the Mc Burney incision a longitudinal cut is made through the skin and the apo neurosis of the external oblique, begin ning one-half inch inside the anterior spine of the ilium, and extending to the linen semilunaris. The fibres of the ex ternal oblique are thus cut across, but the fibres of the internal oblique and transversalis are separated as in the illellurney operation. The wound is closed by passing two rows of sutures through all the layers of the abdomen. to prevent a dead space, and uniting the cut edges of the external oblique with a continuous, buried, silk suture. No nerves or muscles are cut; there is no resulting anesthesia of the skin. The aponeurosis of the external oblique has united well in every case. Elliot (Bos ton Med. and Surg. Jour., Oct. 29, '96).