These operations should then be considered under these different headings:

Under the above headings conditions vary so widely that they can scarcely be spoken of or described under the same name. The seat of the disease should first be approached. Here there is wide range for choice of location of incision and even the method of its performance. Some prefer the outer border of the rectus, others go through the rectus muscle proper by an incision parallel to its fibers, which when exposed are separated, its sheath both anteriorly and posteriorly being divided separately. Others go through the abdominal wall by incisions more or less oblique, and made near the anterior superior spine, where are found the different layers of the abdominal muscles arranged in proper order, their fibers being disposed at right angles to each other. That incision is best in each case which affords the shortest and easiest route to the site of the lesion when it can be located. If tumor be present it is ordinarily best to go in directly over it. In the absence of tumor the point of greatest tenderness is the best guide. The possibility of subsequent hernia at the site which is weakened by operation should be taken into account. If it be possible to avoid drainage hernia may usually be avoided. When drainage is necessary hernia is sometimes unavoidable. The advantage of operation through the rectus is that the muscle fibers can be separated without dividing them. Incision here may, however, carry the operator so far from the site of the appendix that he must necessarily disturb the interior arrangement more than is advisable, and thus increase the danger of infection. The oblique exterior incisions near the ilium always permit of separation of the fibers of the external oblique. The deeper muscle fibers which cross at nearly a right angle may sometimes be nicked and widely separated by firm traction, as in the so-called “gridiron method,” or they may require division. A short external incision is desirable when it suffices for the purpose. Considerations of safety (i. e., the better exposure and easier removal of the appendix) may call in some instances for long incisions, and they should be made sufficiently long for his purpose.

It will often happen that as the surgeon passes more deeply toward the peritoneum he will find the tissues more or less edematous. This is a reliable indication of the presence of pus beneath, and should make him open the peritoneum with care and then use extreme caution in his further manipulation, lest by separating recent adhesions he permit pus to escape. The peritoneum being opened sufficiently the finger is gently insinuated, and thus the first orientation concerning internal conditions is obtained. With the exploring finger there should be ascertained, first, the existence of any adhesions; second, their location and relative firmness, and, third, in a general way, the amount of surrounding disturbance. With an appendix placed anteriorly we may thus come directly upon it, while when placed deeply and posteriorly we may have much to do before reaching it. After the first general exploration the next procedure should be to protect and wall off the region involved from the rest of the abdominal cavity by strips of gauze. These should be long and so secured that none may be lost by being left within the abdomen. The introduction of gauze for this purpose will sometimes increase depression and decrease blood pressure, but it is a necessary procedure in nearly every instance. Moreover, several strips may be needed, and the incision may have to be extended to a limit of two or three inches, according as further exploration reveals a more complicated situation. The fluid pus which may escape should be gently removed with dry gauze, or, if present in considerable amount, be carefully conducted toward the surface. Loops of bowel or tissue bound together by lymph should be gently separated, as they may easily tear, or since imprisoned between them there may be found small collections of pus. If found gangrenous the situation is thereby seriously complicated, and it is advisable not to restore such a loop to the abdominal cavity.

The omentum, as already indicated, may serve as a valuable guide to the location of the appendix, which may be found wrapped within it. It should be handled with great caution, while, at the same time, it is made to reveal the desired information. When the omentum is infiltrated, contorted, and adherent we may be sure of finding pus concealed within the cavity which it helps to wall off. That which is already gangrenous should be removed, with use of sutures in such a way that there shall be no subsequent bleeding. It may be found easily, or not until many other details have been mastered. The involved appendix, when found, may be in one of the conditions described above, all of which demand its removal save those where this has been already accomplished by violence of the disease, in which case the opening in the cecum may have to be closed, or one may employ it for the purpose of an artificial anus. The appendix is often so hard to find that any reliable guide will be welcomed. Such a guide may be found, first, in the location and relation of the omentum, and, secondly, in the cecum if this can be exposed, or in either one of its firm, longitudinal, white tissue bands, which, leading down on either side of the colon, meet and blend at the point of origin of the appendix. Either of these followed in the right direction leads to this spot. Conditions may be such, however, as to obscure both of these guides, and then the colon should be followed downward toward the ileocecal valve, or the small intestine up toward it, in the belief that in this vicinity, and probably in the centre of the tumor, the appendix will be found. What the surgeon shall next do depends on the details of each case. He has not only to remove the diseased appendix, but to ligate and separate from it its mesentery; furthermore to separate either or both of these from surrounding tissues or organs, e. g., the wall of the pelvis, the ovary, the bladder, the retroperitoneal tissue above the sacrum, or from the lateral or anterior abdominal wall. This separation may be easy, or in its performance the tube may rupture and both pus and fecal matter escape; or perforation may have already occurred and the operator will be conducted into a cavity containing matter, pus and fecal mixed, in which perhaps fecal concretions of considerable size will be found loose. He is fortunate who, finding a condition of this kind, finds at the same time that he is still within a circumscribed cavity. This he should respect, and, while endeavoring to clean it thoroughly and drain it, he will avoid doing further harm by breaking down its walls.

Another condition which may arise after the peritoneum is opened is that of escape of a quantity of seropurulent fluid or of almost clear pus which is free within the abdominal cavity. There may be little or much of this. When present it should be removed by gentle sponging before the gauze packing is introduced. Some operators are inclined to irrigate freely and endeavor to wash out all this contained fluid. Others are opposed to this method and believe that gentle dry sponging is preferable. When the appendix is found free and movable, and when the tissues in previous contact with it are free from evidences of destructive infection (as, for instance, when peritoneal surfaces have not lost all their glimmer or sheen), one should carefully remove it, cauterizing its stump, burying it beneath the surrounding peritoneum, and close the abdomen without drainage. In spite, however, of the assertions and actions of some operators, I believe it to be the wisest rule to lay down for general application that it is safer to drain in every case where free pus or breaking down exudate is discovered.

The question of drainage thus raised is as important as any connected with this subject. When and how shall one drain is a question upon which hundreds of pages have been written by various operators, and one which, while settled for individuals, can hardly be settled for the profession at large by any brief statement. Inefficient drainage is almost as bad as none. Efficient drainage may call for the insertion of a tube into the depths of the pelvis, even for counteropening in the cul-de-sac, or for additional opening in the loin, or for the employment of two or three tubes and drains of various kinds. A large tube loosely packed with gauze, perhaps split through its length and abundantly provided with openings, is probably the most effectual drain for most purposes. The cigarette drain, of gauze wrapped in oiled silk, or a few folds of oiled silk loosely tied together, along which fluid may percolate, may be sufficient for cases of lesser extent. Large foul cavities are better left more widely open, and abundantly drained with gauze packing, in spite of the humorous stigma which has been cast upon some of these methods by Morris with his expression “committing taxidermy upon patients.” The depressing reflex influence of such packing being readily conceded it may be regarded as the lesser of two evils.

Another almost equally important question is that of treatment of the peritoneal cavity when involved. Here methods and opinions have varied widely. A peritoneal cavity once inflamed cannot be made absolutely clean in any way, and much reliance should be placed on the properties of the membrane itself, which, to a large extent, should act as its own scavenger. When, however, by removing the parts evidently diseased we have taken away the main source of infection we may feel like relying upon the natural protective forces of the human body; still even here opinions differ. Thus some would flush the abdomen with hot saline solution and even leave some portion of it there, closing the external wound, while others would carefully avoid the introduction of anything by which infectious material may be spread; and while each method has much to justify it one is scarcely found preferable to the other. I believe, however, in thoroughly cleaning out any distinct abscess cavity, and if the pelvis be such then I would irrigate it. I would also thoroughly drain it.

The attention of the reader is here directed to the general considerations found earlier in this work concerning the general technique of abdominal operations, and the matters of drainage and after-care, it being scarcely necessary to reiterate what has been there said regarding the general use of saline solution locally and by the rectum, the advantage of the Fowler position, or of Murphy’s method of slow and gentle introduction of saline solution into the rectum, providing for its continuous absorption, etc.

The possibility of appendicitis leading to general peritonitis, this to acute obstruction of the bowel, and this possibly even to multiple gangrene, has been mentioned. What should best be done under these circumstances must depend upon the patient and upon the surroundings. With a patient too much reduced to justify any prolonged operation the surgeon would probably content himself with evacuation of pus which may be readily reached, and then perhaps by the formation of an artificial anus. Cases which will justify such extensive operation as that above reported by myself in this connection, where it was possible to successfully remove nearly nine feet of intestine, will be exceedingly rare, as well as impracticable in the ordinary private house.