you will not scatter pus or destroy the wall of adhesions which encloses the depot of infection. Success in these operations depends largely on the use of a proper system of gauze packing. On opening the abdomen the wound is first carefully surrounded with gauze strips, as already described, passing between the abdominal parietes and the superficial layer of intestines wherever they are not adherent. The next step consists in the application of the gauze about the coils of intestine which are

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... tted together to retain the infectious material. The operator should palpate with the utmost gentleness to ascertain what portions of bowel are non-adherent and therefore to be isolated from those nearest the appendix by the protective packing. These deeply seated strips of packing material are to be carried well back to the posterior parietal layer of peritoneum. They must touch one another from side to side and must be spread out evenly. All knots and coils of gauze must be avoided with great care. This can be accomplished most easily where the end of each gauze strip can be carried to its destination on the tip of the finger. No strip is to be folded longitudinally upon itself in order to fill up cavities. When spaces are to be filled in, additional pieces of gauze are to be used, each one coming to the surface of the abdomen by as a direct a route as possible. The infected area is not to be encroached upon for any purpose, diagnostic or therapeutic, until the peritoneum is protected by gauze. Once the operator is sure of his protective gauze the infected area is to be opened and drained. This is done deliberately by working the finger gently between the adherent coils of intestine until the exudate is reached. Direct drainage to the cavity is then affected by a strip of gauze which may enclose a tubular drain if the operator desires. If removal is not practicable, the intestines are carefully retracted with gauze compresses or strips and the drains inserted deeply enough in the track of the pus to assure the operator with reasonable certainty that no pockets of pus are without a vent. It is much safer to carry the drainage down to the appendix itself, even if it is not removed. The location of the inflammatory focus with reference to the great barriers to the spread of infection is of the first consequence in estimating the safety and justifiability of these manipulations. Foci situated between the ascending colon and the right lateral abdominal wall offer conditions relatively very favorable to manipulation, since the colon acts as a watershed to turn the course of infection from the main part of the abdominal cavity. Before opening such a focus the surgeon takes care that the space between the anterior surface of the colon and the abdominal wall, if not obliterated by adhesions, is protected by gauze strips and that the upper and lower boundaries of the infected area are well protected by packing to prevent the infectious matter from traveling upward toward the liver or downward toward the pelvis. This technique needs but slight variation when the appendix lies farther down i. e., in the internal iliac fossa. It is when the inflammatory disturbance lies mesially to the colon and above the ilial mesentery that the greatest difficulty exists in protecting the peritoneum during the operatian and in draining adequately afterward. In the language of Harris, " However well we may pack around with gauze, it is often impossible to prevent pus escaping into the general cavity with a resulting fatal peritonitis."3 Presupposing that adhesions are slight or altogether absent, it is absolutely essential that the patient be placed upon a table which can be adjusted to the Trendelenburg position. The pelvis being elevated, the abdomen is opened, the gauze strips having been adjusted as usual about the wound, aseptic compresses are so placed as to receive any infectious matter emanating from the appendical region, and if any adhesions are present at all, the most delicate manipulations must be made in order to leave them intact and a drain of gauze, with perhaps also a tubular one, is to be passed down to the appendix. Should delicate adhesions be disturbed peristaltic action may carry the liberated small intestines to a distant part of the abdomen in a few hours together with the actively infectious matter adherent to their walls. It should be mentioned that transperitoneal drainage has often seemed to various surgeons more hazardous than direct drainage of pelvic accumulations through the vagina or rectum. One of these routes may occasionally be used with advantage. If the inflammation has existed for a length of time sufficiently great to allow strong adhesions to form, binding an abscess wall to the abdominal parietes, it is the surgeon's duty to seek the most direct route to the abscess interior, the incision through the abdominal wall being made in such a way that the free peritoneum will not be injured. When abscesses are situated in the right iliac fossa adhesions will oftentimes be firm between the walls of the abscess and the outer abdominal parietes, even though the anterior wall be free. The incision in such a case should be made well to the outside of the focus of inflammation or even in the lumbar region. The gauze drain should not be removed until five to eight days have elapsed, giving ample time for adhesions to have walled off the infected area. The ideal suture is one that, first, can be most readily and easily introduced; second, that holds the parts in perfect apposition with the least possible interference to the circulation of or at the edges of the wound; third, that is the least apt to become septic; fourth, that requires the least possible amount of suture material; fifth, that leaves the least possible scar; sixth, that can be relied upon to fulfill these requirements and after fulfilling them, can be removed. The old interrupted en masse suture, while fulfilling the first requirement of introduction well enough, utterly fails in all the rest except the last, viz.: removal, for by including the tissues from one-half to one inch on each side of the wound and tying them, the circulation is materially interfered with, thus preventing healing and promoting sepsis by reducing the blood supply and depriving nature of its best means of keeping the wound disinfected and promoting its rapid repair.