To easily locate the appendix and facilitate free drainage, an incision is made through a more muscular and dependent portion of the abdominal wall an inch above and parallel to the crest of the ilium, beginning at the outer edge of the external oblique, and run ning forward to a point corresponding to the anterior superior iliac spine, or, if necessary, slightly beyond this. Hav ing divided the skin and aponeurosis, the external oblique, which is found well developed at this point, and its fibres running nearly vertical, is separated. after which the internal oblique and transversalis, which are also well devel oped, and whose fibres run nearly on one plane, are separated, exposing the trans versalis fascia. This, together with the peritoneum, is divided in a vertical direc tion. This will be found to have opened the peritoneal cavity at its lowermost plane and near to the attachment of the crecum. A finger, now being introduced, invariably comes in contact with the caput eoli, which can be readily drawn into the wound, and thereby facilitate the search for the appendix. In sup purative cases, the pus-cavity being opened at this point, drainage follows at the most dependent point. The great est disadvantages are the depth of the wound and haemorrhage from a small muscular branch of the circumflex iliac artery, which can readily he controlled. Tischer (Annals of Surg., Nov.. '07).
"Hoekey-stick" incision in appendicitis admits of the fibres of the oblique and transversalis being separated and not cut transversely; at the same time sufficient room is obtained, not only for the re moval of the appendix, but for meeting any complications that may exist in the pelvis upon the right side. The incision begins above, midway between McBur ney's point and the anterior superior spine of the ilium. It descends parallel with a line drawn from the pubis to the anterior superior spine, and, when above Poupart's ligament on a line the femoral artery, curves at an obtuse angle and is extended as far as the border of the rectus muscle. In making the hori zontal part of the incision care must be taken not to injure the epigastrie artery. Willy Meyer (Jour. Amer. Med. Assoc., Feb. 17, 1900).
New method of opening the abdomen in cases of simple appendicitis: The skin incision confluences at the upper rounded prominence of the anterior superior spine of the ilium and is carried almost hori zontally to the outer edge of the rectus, from which point it is curved downward for about two and one-half inches. The triangular flap is then dissected down ward and outward, exposing aponeurosis of the external oblique. A retractor is applied at the lower angle of the wound and at the middle of the trans verse incision, and traction exposes three inches of the aponeurosis, which is di vided in the direction of its fibres. Two
more retractors are applied and the sheath of the reetus exposed likewise and opened. The rectus muscle and deep epigastric vessels are retracted median ward, exposing for four inches in a transverse direction the internal oblique and its aponeurosis. A transverse in cision is now carried down through the remaining layers into the abdominal cavity, making a wound which by proper retraction gives ample room for an ap pendectomy. In closing the wound the different layers are closed by continu ous sutures running in the lines of in cision, care being taken in suturing the external oblique aponeurosis that the sheath of the rectus abdominalis is in cluded. Fowler (Med. News, Mar. 3, 1900; Phila. Med. Jour.).
Method of operating on appendicitis by incising the external oblique fascia and then forcibly separating the muscles is so superior to the older method of cutting through the muscle in the pre vention of hernia that it is the operation par excellence in many cases. It, how ever. does not provide sufficient room for the complicated cases, and the incis ing of the intermuscular space upward along the border of the rectus has proved unsatisfactory. Proposition to gain the necessary room by tearing the denuded fascia of the external oblique from the sheath of the rectus quite up to the median line. The anterior sheath of the rectus is there divided transversely in a line continuous with the opening made in the peritoneum by the original muscle separation operation. The reetus muscle can now be retracted medianward and, after ligation or retraction of the epi gastric vessels, the posterior sheath and peritoneum can be cut in a direction similar to the anterior sheath. The procedure allows the greatest access pos sible to the right iliac fossa. The sheaths of the reetus should be closed with cat gut. it. F. Weir (Phila. Med. Jour., from Med. News, Feb. 17, 1900).
The abdominal walls having been penetrated, the margins of the wound are then retracted by an assistant, unless the abscess has already reached the sur face. The peritoneum is then divided freely. but with great care.
Matted coils are gently separated and intestinal prolapse and contact with dis eased surfaces are prevented by carefully packing the cavity around the ace= with pads of iodoform gauze, the ends . remaining outside or being held by clamps. This should be done in such a manner that no infected tissue or fluid be in any way brought in contact with the healthy peritoneum. The walls of the pus-cavity are then disinfected with a bichloride solution of 1 to 5000.