The closure is begun by drawing back the muscles with tenacula, and with a curved needle, and the catgut already tied into the peritoneum closes the peritoneum, using continuous suture. Tie and cut off the suture. With the tenaculum draw the two outer muscles toward the median line and begin the suture in the transversalis, allowing the muscles to come toward the outside as the suturing continues. By retracting in the direction of the split that is being closed, the opening can be kept over the part of the incision that is being sutured, thus giving plenty of room. The muscles move freely over each other and can be retracted for a considerable distance. The internal and external oblique are sutured in like manner, using plain No. 2 catgut. The skin is closed by subcuticular suture of plain No. 1 catgut and covered with collodion.

The advantages of this incision are self-evident. No muscles are cut, they are split. When a muscle is cut across and sutured, when it contracts, the whole force is directly against the suture, and the space between the sutures separate to some extent. This gives pain and takes a long time to heal. If the muscle is split in the direction of its fibres and is sutured together, when it contracts, it has a tendency to close and does not draw upon the sutures. There is nothing to heal except the connective tissue, which heals in a few days. Fig. 7 shows the two sutures. The muscles slide freely over one another and the opening in the different layers does not stay in the same relation to the others, thus lessening the danger of hernia.

There is no cicatrix binding all of the muscles together and acting as a splint, as in the straight through cut. There is less risk of hernia, there is less pain, the healing is quicker, the scar hardly noticeable. The patient is not confined to the back, but allowed to turn over at will, from the first. This stimulates peristalsis and lessens the trouble with gas. There is not so much exposure of the viscera. No sponges are introduced when the appendix has not ruptured, so there is no lint for the peritoneum to care for. There are no sutures to remove, and the patient may be allowed to leave the bed in from five to seven days, and to leave the hospital in from

eight to twelve days with no increased risk and no discomfort.

The patient whom I present to-night was operated upon eleven days ago and has been out of the hospital since eight

and a half days. He had an acute attack of twenty-two hours duration. The appendix was nearly as large as my finger, distended with pus, and had two dark spots, which I feel confident would have given way in a few hours. He had no trouble with gas, the bowels moved voluntarily on the second day. He sat up in a chair on the sixth day and afterward was allowed to walk around the hospital.

I operated upon a nurse who left the hospital on the tenth day. She had no trouble and very little pain. This was a case as shown in Fig. 8, No. 1, of mucous occlusion from a short meso-appendix.

In the case of a lady who had abscess formed, the appendix had sloughed off, and the pus emptied through the resulting opening into the bowel. The degenerated appendix was in a mass of omentum. I drew up the bowel, and put some Lambert sutures over the opening, broke up the adhesions around the mass of omentum, drew it out, ligated it and removed it. She left the hospital on the thirteenth day.

In six cases where I have used this incision, the shortest time in the hospital was eight and a half days, the longest thirteen days.

Fig. 8, Nos. 1, 2, 3, represent three non-suppurative types of appendicitis which require operation. The short mesoappendix, causing mucous occlusion, the strictured appendix and the obliterating appendicitis. These three varieties represent the mild recurrent types and are quite painful and disturb the whole alimentary tract.

CLINICAL NOTES

ON THREE CASES OF APPENDICITIS.

ALFRED MOORE, M.D.

MEMPHIS.

I SHALL confine my remarks mainly to the report of some cases that can not be classed symptomatically as typical of this disease, and yet we have identically the same pathological condition present, which, if overlooked, and not treated surgically, but left to nature, may cause irreparable damage.

*Read before West Tenn. Med. and Surg. Assn., Jackson, May 19-20, 1904.

During my service as an interne, and since, I have had occasion to witness and assist in many cases in which the operators were surprised at the unexpected condition, and one case especially where the patient presented himself during "an interval" for an operation and the appendix was found swinging in the abdominal cavity with thin walls and distended with pus. The cases which I wish to report may be of some interest and are, briefly, as follows:

Case I. Male, white, 21 years old, married, and up to the last few months previous to this attack, was strong and healthy. For one or two months he has been troubled with indigestion and occasional nausea, constipation or diarrhea, though he did not think it severe enough to see a physician. When I saw him the first time he complained of pain over the abdomen and in the right testicle. The temperature was only 99° F., and pulse slightly accelerated. There was slight rigidity of right rectus muscle. Deep pressure in right iliac fossa did not cause him to complain, though he afterward told me that it pained him a great deal, but he was so afraid of appendicitis that he would not say anything. I suspected the appendix to be the offender in this case, and had several consultations with another physician, who at first disagreed with me, but after four or five days decided that it was appendicitis and favored an operation, which I did as soon as I could make the necessary arrangements. The bowels were moved freely with calomel and enemata. The temperature slowly went up and was only 103°F. when operated upon, five days after I first saw him. His pulse was 90, and a small tumor could be palpated over the appendix. The abdomen was opened and about two drachms of very foul pus evacuated. The appendix was found sloughed off. Nature had thrown out adhesions and it was well shut off from the general peritoneal cavity which I did not disturb. The wound closed in about four weeks and patient was then allowed to leave the hospital.

Case II. Male, white, 23 years old, single, strong and healthy up to two months previous to this attack, when he had a similar attack, but his physician did not advise an operation. He had been attending to his business since, but was annoyed by constipation and indigestion. The present attack commenced with violent pains over the abdomen and vomiting. The pain over the abdomen was so intense that I had to administer morphin to examine him. The tempera