On the Compression of the Front of the Feet
Boston Medical and Surgical Journal
transversalis are separated without cutting. When the appendix has been removed, the opening tends to close of itself, as the muscular fibres fall into their natural place. I have done this operation ten times, and have been much pleased with it. When the appendix is in its normal position and is not difficult to get out, it is almost an ideal operation ; but when difficulties arise and the incision has to be enlarged, it has certain serious objections. The first objection is that in difficult
... that in difficult cases the necessarily constant and hard retraction' of the muscles is apt to injure the tissue of the wound surface so as to make its healing lesa perfect, and sometimes to cause suppuration. Another objection is that if it is found necessary to enlarge the wound, not only is the advantage of the original McBurney incision lost, but we have a ragged and complicated wound with two muscular layers stripped widely apart. Such a wound is not well adapted to drainage if pus is unexpectedly found. To meet these objections I begin the operation by making a horizontal cut through the skin and the aponeurosis of the external oblique, beginning one-half an inch inside the anterior superior spine of the ilium, and extending to the linea semilunaris. The fibres of the external oblique are thus cut across, but the fibres of the internal oblique and the transversalis are separated as in the McBurney operation. In my operation the whole incision is a cross cut, the external and internal incisions running in the same direction. There is no stripping up of the external oblique. This incision can readily be enlarged upwards or downwards in the linea semilunaris, or may be extended into the rectus if necessary. In closing the wound I pass two stitches through all the layers of the abdomen, to prevent a dead space, and unite the cut edges of the external oblique with a continuous buried silk suture. I have done nine cases by this incision, and the results have been very satisfactory. (Patients were shown at the meeting.) As in the McBurney operation, no nerves or vessels are cut. There is no resulting anesthesia of the skin. The aponeurosis of the external oblique has united well in every case, and I see no objection to cutting it. In one case, where it became necessary to curette and drain a softened mesenteric gland, no suture was used ; and yet the cross-cut incision showed no tendency to gape open, but, on the contrary, the wound healed by granulation after the gauze drain was removed, and has shown no tendency to hernia. By this incision, with the patient in the Trendeleuburg position, the cecal region can be easily and thoroughly explored, and the appendix can be dissected from behind the cecum or from the brim of the pelvis. As the cross-cut incision can be made directly over the base of the appendix, it has the advantage of directness when compared with an incision in the linea semilunaris.