THE OPERATION ITSELF IN APPEN- 
DICITIS. 
BY 
OF LOUISVILLE, KY.J 
PROFESSOR OF GYNECOLOGY AND ABDOMINAL SURGERY IN THE HOSPITAL 
COLLEGE OF MEDICINE. 
LEWIS S. M'MURTRY, M.D., 
FROM 
THE MEDICAL NEWS, 
October 9, 1897. [Reprinted from The Medical News, Oct. 9, 1897.] 
THE OPERATION ITSELF IN APPENDICITIS.1 
OF LOUISVILLE, KY.; 
PROFESSOR OF GYNECOLOGY AND ABDOMINAL SURGERY IN THE 
HOSPITAL COLLEGE OF MEDICINE. 
By LEWIS S. M'MURTRY, M.D., 
Hitherto our discussions upon appendicitis have 
been directed for the most part to the pathologic 
condition as related to symptomatology with a view 
to early diagnosis and determination of the question 
of operative interference, with only brief and inci- 
dental consideration of the operative technic. The 
multifarious types presented by the disease, the 
variety in character and extent of the lesions, the 
several stages of progress in which operation is per- 
formed, the complications and sequelie, compose a 
series of requirements in operating which may only 
be successfully met by the best surgical judgment 
and operative skill. In view of these facts, and the 
additional one that the profession has very generally 
come to recognize appendicitis as a strictly surgical 
disease, cured only by operation, I have selected 
the operation itself as an appropriate and profitable 
theme for discussion at this time. 
I propose to consider the subject under the follow- 
ing heads: (i) The incision. (2) Dealing with ad- 
hesions and with abscesses. (3) Removal of the 
appendix. (4) Drainage and isolation of the peri- 
toneum by gauze. 
1 Read at the Tenth Annual Meeting of the American Associa- 
tion of Obstetricians and Gynecologists, Niagara Falls, N.Y., 
August 17-20, 1897, 2 
The Incision.-Concerning the incision, three im- 
portant considerations must be observed, the first 
being to obtain easy access to the caput coli, with 
sufficient working space, the second, to secure all 
natural advantages to facilitate drainage, and the 
third, to secure complete repair of the parietal struc- 
tures incised and thereby prevent the occurrence of 
hernia. 
The early operations for appendicitis were mostly 
undertaken in extreme cases, in which suppuration 
had occurred, and consisted in cutting into the abscess 
and evacuating and draining the same. For this 
purpose the vertical incision was adopted and is yet 
practised by many surgeons. This incision is made 
along the external border of the right rectus muscle, 
a little to the inner side of the right semilunar line. 
It should intersect a line drawn from the anterior 
superior iliac spine to the umbilicus, very nearly 
midway, and should be about three inches long. 
The sheath of the rectus had best be pushed aside 
slightly and not opened, so as to lessen the amount 
of bleeding. The muscles and fascia having been 
divided, the peritoneum is opened, and the caput 
coli found immediately beneath by the exploring 
finger. Kocher has called attention to the fact that 
a branch of the iliohypogastric nerve, which enters 
the sheath of the rectus, is divided by this incision. 
Atrophy of that part of the muscle supplied by this 
nerve has been observed after the operation. This 
incision furnishes good access to the parts involved; 
and when made and sutured under the protection of 
thorough asepsis, with proper management afterward, 
restores the integrity of the abdominal wall. In my 3 
early operations performed in this way, comprising 
a series of twenty-seven cases, mostly in the suppu- 
rative stage of the disease, the results were quite 
satisfactory. So far as I am aware, not one hernia 
occurred in the entire series. 
The vertical incision does not, however, give as 
easy access to the appendix and to the outer and 
posterior areas adjacent thereto (which are so fre- 
quently involved) as does the oblique incision. The 
latter is preferable also for drainage, and affords an 
additional advantage by diminishing the danger of 
breaking through the inner wall when an abscess- 
cavity has formed about the appendix. This incision 
is made parallel with Poupart's ligament and trav- 
erses the line from the anterior superior iliac spine 
to the umbilicus well over to the right side. It en- 
ables the operator to explore the right iliac fossa 
from the external boundary, thus giving protection 
to the general peritoneum which may already have 
been shut off by protecting adhesions. In my recent 
work I have operated altogether through this oblique 
incision. 
A method of dividing the abdominal wall by a 
combination of incision and blunt dissection has 
been described by McBurney and commended by 
many writers on the surgery of the appendix. This 
is an oblique incision, in which, after dividing the 
skin and superficial fascia, the fibers of the parietal 
muscles are separated by a blunt instrument and held 
apart with retractors while the peritoneum is divided 
and the appendix removed. This incision is only 
applicable to non-suppurative cases, according to its 
author, though some operators claim to have advan- 4 
tageously extended its application to those in' which 
suppuration has taken place. The theory of this in- 
cision, of course, is that by tearing apart the bundles 
of fibers of the abdominal muscles, instead of divid- 
ing them by incision, the natural crossing of fibers 
in the muscular structure of the abdominal parieties 
is preserved, thereby preventing hernia as a post- 
operative sequel. These refinements are not practi- 
cable in cases of perforative appendicitis in which 
the life of the patient depends upon thoroughness of 
operation and free drainage. Moreover, it is doubt- 
ful if separating muscular structures with a blunt in- 
strument yields any advantage over the division of 
those structures by incision, provided all proper care 
is bestowed upon closure and retention of divided 
parts by suturing. In grave cases of appendicitis, 
in which the patient's life hangs trembling in the 
balance, the incision should be made with a view to 
gaining access to the parts with sufficient working 
space and free drainage, other considerations being 
secondary. 
In cases of recurrent appendicitis, in all cases in 
which there is no pus outside the appendix, and in 
all cases in which the requirements are properly met 
by a single drain, the utmost care should be bestowed 
upon the suturing of the incision. In these cases I 
have used the through-and-through suture with silk- 
worm gut, together with immediate suture of divided 
muscle and aponeurosis with interrupted sutures of 
catgut. In these non-suppurative cases the silkworm- 
gut sutures should be allowed to remain for ten or 
twelve days. In suppurating cases, when extensive 
gauze packing and drainage prevent immediate clo- 5 
sure of the incision, one angle of the wound should 
be brought together as far toward the middle of the 
incision as practicable, and the remaining sutures of 
silkworm gut left untied until they may be utilized. 
The latter are the cases in which hernia is so often 
a sequel to operation and I do not see that any 
method of suture can overcome this danger. They 
are really cases in which the open treatment is an 
absolute necessity. Patients treated in this manner 
should be required to remain in bed much longer 
than is customary, until organization and consolida- 
tion of the new tissue formation uniting the incised 
parieties are complete. This will do more toward 
the prevention of hernia in this class of cases than 
any particular method of incision or partial closure 
of the same. 
Adhesions and Abscesses.-In dealing with adhe- 
sions and abscesses the same general rules of surgical 
treatment should be observed in appendicitis as in 
similar conditions affecting other organs enclosed 
within the peritoneum. Whenever practicable, ad- 
hesions should be separated, abscesses emptied, dis- 
integrated structures composing foci of infection 
removed, and cleansing and drainage secured by 
measures of assured efficiency. It is an established 
procedure in pelvic surgery to incise and drain ac- 
cumulations of pus in exhausted subjects as an operT 
ation of expediency, looking to improved conditions 
for radical operation and permanent cure. In a 
limited proportion of cases, Nature completes the 
cure after such an incomplete operation. The same 
methods and similar results obtain in the treatment 
of appendicitis. The function of surgery is to save 6 
life; the attainment of ideals should be altogether 
subordinate to this supreme indication of all surgical 
operations. This axiom is eminently applicable to 
the disease under consideration, and, at the same 
time, we must concede that incomplete operations 
do not, as a rule, beget cures. In all operations for 
appendicitis, in all stages and varieties of the disease, 
the appendix should be removed whenever the pa- 
tient's condition will permit completion of the oper- 
ation. I am aware that many excellent surgeons 
endorse and pursue the practice of evacuating an ap- 
pendicular abscess cavity, affording drainage, and 
partially closing the incision without any attempt to 
remove the appendix and close the cecum at the 
point of sloughing. Though this may be the better 
practice for the occasional operator, it is far from 
safe to leave within the abdomen a perforated and 
sloughing appendix. While a certain proportion of 
these patients recover under an incomplete opera- 
tion, the aggregate of results, including cases of 
fecal fistulse and secondary operations, is not equal 
to that of completed operations. This convic- 
tion has not been formed from theory or by anal- 
ogy. I have opened appendicular abscesses which 
have burrowed along the intermuscular planes to a 
point in the lumbar region, and other remote points 
and in numerous instances the patients have recov- 
ered after protracted convalescence. On the other 
hand, I can cite numerous instances in which this 
procedure has failed. Four years ago I operated on 
a young woman, aged twenty-four, with suppurative 
appendicitis. Her condition was critical when first 
seen and operation was promptly performed. On 7 
opening the peritoneum through the usual incision 
and introducing the finger, pus poured from the 
wound. The insertion of a drain completed the 
operation. Convalescence was imperfect and ten 
days later the pulse, temperature, and general symp- 
toms gave unmistakable evidence of continued sup- 
puration. A second operation was performed and 
an abscess posterior to the cecum evacuated. The 
abscess-cavity was irrigated and deep drainage estab- 
lished. The patient made an incomplete recovery 
and suffered another attack three months later, when I 
again operated and removed the inflamed stump of an 
appendix. Recovery was prompt and the cure com- 
plete. Much suffering and no small risk to life would 
have been avoided had it been practicable to com- 
plete the operation with safety the first time. I do 
not mean to question the wisdom of refraining from 
searching for accumulations of pus by separating ad- 
hesions, from searching for the appendix, and from 
completion of all details when the patient is too 
feeble to bear such an operation. But when it is 
practicable to do so, I am sure the patient's welfare 
is best subserved by a complete operation. 
In some cases of appendicitis, known as the fulmi- 
nant type of the disease, the progress is so rapid 
that no confining wall of lymph is formed. In such 
cases the peritoneum is filled with serous effusion 
mingled with flakes of lymph, and general septic 
symptoms proceed with great rapidity. A perforated 
and gangrenous appendix will be found. Thorough 
irrigation of the peritoneum far and near, with drain- 
age, constitutes the essential parts of the operative 
procedure. 8 
The most common abscess location, in my experi- 
ence, is posterior to the cecum. The exploring 
finger, passed down beside the external surface of 
the cecum, will enter the abscess-cavity. Less fre- 
quently the abscess will be found anteriorly. The 
omentum, cecum, and coils of intestine, with the 
parietal peritoneum compose the confining area. 
The appendix will be readily found in the abscess- 
cavity. Again, the pus may be confined by adhesions 
within the pelvis. These are the cases in which 
fluctuation maybe detected by rectal palpation. 
In these several locations the general peritoneum, 
preparatory to evacuation, should be isolated by 
careful packing of gauze. When the abscess is post- 
cecal, long strips of gauze should be carefully tucked 
in position before carrying the exploration to evacua- 
tion of the abscess. There are three directions for 
gauze packing under these circumstances-in the 
pelvis, toward the median line, and toward the lum- 
bar region. As the pus is evacuated, the patient is 
turned toward the right side and the pus carefully 
wiped away with loose gauze pads. The cleansing 
should be completed by thorough irrigation with 
warm salt solution, using for this purpose a small 
glass nozzle attached to the irrigator. Careful and 
gentle exploration should be made for additional ac- 
cumulations of pus. When the abscess formation is 
localized in the other regions indicated, the same 
methods of evacuating and cleansing, with proper 
protection of the outlying peritoneum by gauze, 
must be observed. My experience compels me to 
look to thorough irrigation as the most potent of all 
our resources in this all-important part of the opera- 9 
tive procedure. I place no reliance upon the use of 
peroxid of hydrogen, iodoform, or other chemic 
germicides here, but believe mechanical cleansing by 
washing, with the accompanying attenuation, will do 
more to arrest septic processes and save the patient 
than all other agencies combined. 
Removal of the Appendix.-The cecum appears in 
several types in the adult, four distinct typical forms 
being described by anatomists generally. The ap- 
pendix in man is the cecum of some lower animals 
in an undeveloped state. In the early period of fetal 
life the cecum with its vermiform appendix is near 
the umbilicus and descends into the right iliac fossa 
about the sixth month. Abnormal positions of the 
appendix, such as to the left of the median line and 
other similar displacements, are due to failure of 
descent of the cecum. The average length of the 
human appendix is about three and one-half inches, 
but it may vary from one to nine inches. While the 
cecum may in exceptional cases be only partially in- 
vested by the peritoneum, as a rule it is entirely 
covered by peritoneum and hence free and mobile in 
the abdominal cavity. The triangular folds of peri- 
toneum forming the meso-appendix are reflected from 
the ileum to the appendix. The artery, vein, and 
lymphatics which supply the organ pass between the 
two layers of the meso-appendix. This process of 
the peritoneum varies in length and thickness, and 
also in the extent of its infolding of the appendix. 
The mobility of the appendix depends upon the 
length and breadth of the meso-appendix, and hence 
has a varying range of movement in various subjects 
within physiologic limitations. In the female there 10 
is a prolongation of the meso-appendix extending to 
the right ovary, which conveys an additional vascu- 
lar supply to the appendix and which has been called 
the appendiculo-ovarian ligament. To this addi- 
tional blood-supply has been attributed an increased 
vitality, rendering women less disposed to appen- 
dicitis than men. The appendiculo-ovarian ligament 
may also facilitate the extension of inflammatory 
processes between the appendix and ovary, which I 
have frequently found to obtain. 
From this cursory recital of some of the important 
anatomic relations of the cecum and its appendix, it 
is apparent that the latter is normally endowed with 
an extensive and varying range of mobility. It would 
be more accurate to say of the appendix that it may 
normally occupy various positions and possess vary- 
ing degrees of mobility in these several locations. 
It has been attempted by Bristow, Fowler, and 
others, to make a definite numerical classification of 
the normal positions of the appendix. Such refine- 
ment of description is of doubtful value as a working 
basis under pathologic conditions. Normally it is 
about the caput coli, often found toward the median 
line, below the pelvic brim, alongside the cecum ex- 
ternally, and even underneath the cecum. 
When fixed by adhesions and surrounded with in- 
flammatory deposits, agglutinating adjacent serous 
surfaces, it becomes a difficult task to find and isolate 
the appendix. In many instances of suppurative ap- 
pendicitis, that organ will have died, appearing in 
the abscess as a black slough. In other instances it 
will have been disintegrated by the destructive proc- 
ess and only a stump will be found to mark its site. 11 
The corrosive process of suppuration will, in some 
cases, erode in spots the structures of the cecum; in 
more than one such case I have found it necessary to 
pare away the rotten tissues and suture the openings 
in the gut. 
When the incision has been completed through 
the peritoneum, the cecum and appendix should be 
brought up through the wound. In non-suppurative 
cases, by following familiar anatomic guides, the 
exploring finger will usually detect the appendix 
before bringing forward the cecum. In suppurative 
cases the greatest difficulties will be encountered. 
The anatomic and pathologic facts already given, 
together with the careful guide of an educated touch, 
must be utilized to discover and deliver the organs. 
When the appendix is in hand, the cecum should be 
returned into the abdomen, and gauze wrung out in 
hot water placed around it. In my early operations 
I ligated the appendix with the meso-appendix, using 
fine sterilized silk, cut away the appendix, and ap- 
plied pure carbolic acid to the stump. Later, I 
adopted the modern method of transfixing the meso- 
appendix at its base, cutting it away, stripping back 
a cuff of peritoneum from the appendix down to its 
junction with the cecum, ligating the appendix with 
fine silk and cutting it away, afterward sterilizing 
the stump, invaginating the stump into the cecum, 
and covering it with peritoneum by careful stitching 
after the Lembert method. Nothing in the progress 
of healing or in ultimate results indicated any ad- 
vantage of the latter method over the former simple 
ligature, excision, and cauterization. Careful study 
of the method of invagination from time to time 12 
persuaded me that its advantages were more theoretic 
than practical. Indeed, if carefully studied with the 
parts in sight, it will be seen that the invagination 
is only into the coats of the cecum. An infected 
ligature would more readily find its way into the 
peritoneum than into the lumen of the gut. More 
recently I have adopted a method of treating the 
stump, which, after I had applied it for some time, I 
found had been published by Dawbarn. It consists 
in passing an interrupted suture of fine silk in a cir- 
cular manner around the stump, catching up the 
peritoneum and bringing it over the stump as with a 
purse-string. I deem this preferable to the method 
of invagination. The silk used for ligature of the 
appendix and meso-appendix, and for suturing, should 
be of the size that will supply requisite strength with 
the least bulk. In cases of recurrent and relapsing 
appendicitis, wherein there is no pus outside the ap- 
pendix, this part of the operation can be most satis- 
factorily completed ; in suppurative cases there must 
be thorough cleansing, and the ligature and sutures 
must be placed in tissues of good vitality if we would 
avoid the troubles of infected ligature and a sinus 
afterward. 
In cases in which the appendix is necrotic, it is 
not sufficient to leave the stump to separate under 
the protection of drainage, provided the patient's con- 
dition will permit prolongation of the operation suffi- 
ciently for proper closure of the point of separation. 
In these cases the necrotic process extends to the 
coats of the cecum and fecal fistula is a common 
sequel. While such a fistula will usually heal spon- 
taneously, it does not always do so, and, when prac- 13 
ticable, this complication should be averted by ex- 
cision and suture of the gut. In these cases the 
dead tissue about the stump should be trimmed away 
with scissors and the opening thus made closed with 
two rows of fine silk sutures. When the patient's 
condition is extremely bad from progressive sepsis, the 
operation should not embrace these detailed atten- 
tions to the stump; but there is a certain proportion 
of suppurative cases wherein with rapid (not hasty) 
work such completed operative work may be most 
advantageously applied. 
In all suppurative cases the clean peritoneum must 
be protected by gauze during the manipulations upon 
the appendix and its stump, both from the foul ap- 
pendix and the bed in which it lay. Throughout 
the entire operation the highest skill of the operator 
will be brought to bear upon the protection of the 
outlying area of peritoneum from infection. 
Drainage and Isolation of the Peritoneum by Gauze. 
-In no class of intraperitoneal operations does drain- 
age perform more essential functions than in opera- 
tions for suppurative appendicitis. In cases of re- 
current appendicitis operated upon in the interval 
of course drainage will not be required. That class 
of cases, also, in which suppuration is confined with- 
in the coats of the appendix, permitting accurate 
sterilization and infolding of the stump, will not need 
drainage. But in the cases in which perforation and 
suppuration have obtained, either with or without a 
limiting wall of exudate, drainage will be a most 
essential part of the operative technic. 
The right iliac fossa is not the most dependent 
pouch of the peritoneum and hence glass tubular 14 
drainage supplemented by suction cannot be applied 
as in pelvic surgery. Here we must rely upon tubu- 
lar drainage with rubber and capillary drainage with 
gauze. Rubber tubing of firm material which will 
bear considerable compression without closure should 
be selected ; and sterilized gauze, untreated by any 
chemicals, is best adapted to this purpose. Gauze 
which has been iodoformized drains very inefficiently, 
its capillarity being impaired by the filling of its 
meshes with the chemic agent. 
The extent of drainage must necessarily vary with- 
in wide limits. In certain cases only a small strip of 
gauze passed down to the bed formerly occupied by 
the infected appendix to prevent too quick closure of 
the parietal incision may be all that is required. In 
cases in which no adhesions had been formed be- 
tween anterior peritoneum, omentum, and visceral 
peritoneum beneath, strips of gauze must be placed 
in different directions so as to assure drainage of the 
general peritoneum. These strips should be placed 
endwise, especial care being given to drainage from 
the direction of the deep pelvis, the spleen, and 
region beneath the liver. The ends must, of course, 
be brought out of the most dependent angle of the 
incision. This drainage had best be supplemented 
by a rubber tube passed down to the area immediately 
about the caput coli where the focus of infection was 
localized. 
After removal of the appendix, and cleansing of 
the peritoneum, strips of gauze should be placed for 
the double purpose of drainage and forming a wall 
between the infected area and the general perito- 
neum. Within twenty-four hours the meshes of the 15 
gauze will be filled with lymph, forming a protecting 
wall. This is a most important function of gauze 
and is utilized with greater advantage here than in 
any other class of operations. The gauze should not 
be removed before the third day, and then one strip 
at a time, beginning with the central piece and pre- 
serving the outlying barriers, until the fourth day. 
After the general peritoneum is securely shut off it 
is only necessary to maintain drainage down to the 
focal area about the head of the cecum. Should dis- 
charge therefrom appear at this time, the drainage- 
track should be frequently washed out. Fecal fistula 
will require constant care to cleanse and protect 
the wound. A fecal fistula which otherwise would 
heal may be kept open indefinitely by persistent 
efforts at drainage. Throughout the period of drain- 
age the patient should remain in bed and union of 
the incised parietes should be facilitated by adhesive 
straps and bandages, with constant recognition of 
the possibility of the occurrence of hernia. The Medical News. 
Established in 1843. 
A WEEKLY MEDICAL NEWSPAPER. 
Subscription, $4.00 per Annum. 
The A meric an Journal 
OF THE 
Medical Sciences. 
Established in 1820. 
A MONTHLY MEDICAL MAGAZINE. 
Subscription, $4.00 per Annum. 
COMMUTATION RATE, $7.50 PER ANNUM. 
LEA BROS & CO., 
NEW YORK AND PHILADELPHIA.