McBurney Incision Research Articles

Segmental nerve damage during a McBurney's incision: a cadaveric study.

Injury to the ilioinguinal and iliohypogastric nerves after a McBurney's incision have been reported to cause paralysis of the conjoint tendon that may lead to the development of an indirect inguinal hernia. This study reports on the incidence of ilioinguinal and iliohypogastric nerve sectioning after the performance of a classic McBurney's incision as well as the distance and relationship of the ilioinguinal and iliohypogastric nerves to the anterior superior iliac spine and a classic McBurney's incision. The right iliac fossa and lumbar region of 33 cadavers were dissected for the uncovering of the ilioinguinal and iliohypogastric nerves after a correct McBurney's incision was made. Injury to the ilioinguinal and iliohypogastric nerves was recorded. The mean distance between the ilioinguinal nerve and the incision line was 41.89 mm and 34.63 mm between the iliohypogastric nerve and the incision line. The ilioinguinal and iliohypogastric nerves were found to be 6.69 mm and 12.08 mm from the anterior superior iliac spine, respectively. No ilioinguinal or iliohypogastric nerve was injured during all 33 McBurney's incisions.

The Possibility of Nervus Ilioinguinalis and Nervus Iliohypogastricus Injury in Lower Abdominal Incisions and Effects on Hernia Formation

Aim. The aim of this study was to determine the distances of nervus ilioinguinalis and nervus iliohypogastricus to McBurney's and paramedian incisions. Materials and methods. This study was performed on 12 adult cadavers. Right and left inguinal regions of the cadavers were dissected by inguinal incision. The points where the nerves perforated the internal obliquus muscles were determined, and the distances of these points to the spina iliaca anterior superior (SIAS) and to the umbilicus were measured. These distances were marked over a diagram, and distances of the nerves to McBurney's and paramedian incisions were measured by illustrating these incisions on the same diagram. Findings. While the distance of the iliohypogastric nerve from the SIAS was 1.5–8 cm on the right and 2.3–3.6 cm on the left, the distance of the ilioinguinal nerve from the SIAS was 3–6.4 cm on the right and 2–5 cm on the left. The distance of the ilioinguinal nerve from McBurney's incision was 0.2–6.1 cm on the right and 1.8–7.5 cm on the left, and that of the iliohypogastric nerve was 2.2–6.9 cm on the right and 2.9–6.2 cm on the left. The distances of the nerves from paramedian incision were found to be 4.6–10 cm on the right and 6.4–11.2 cm on the left for the ilioinguinal nerve and 5–11.2 cm on the right and 7.4–11.6 cm on the left for the iliohypogastric nerve. Conclusion. Both nerves perforate the musculus obliquus internus, scattered in a wide area. Considering the distances, the paramedian incision seems to be more reliable with respect to the risk of nerve injury. Incisions performed in the lower abdomen carry the risk of injury to the ilioinguinal and iliohypogastric nerves.

Traitement de la péritonite appendiculaire de l'enfant par conversion en vidéolaparoscopie: la conversion n'est pas à sens unique

Aim of study After removal of a perforated appendix with generalized peritonitis by a McBurney incision, peritoneal lavage may be performed by videolaparoscopic approach. Patients and methods This method was used in 14 children, seven boys and seven girls, aged from 2.7 to 14 years, with acute appendicitis and peritonitis. Results Conversion to median laparotomy was necessary in order to perform adhesiolysis in two cases in which small bowel was observed. Postoperative complications occurred in four patients involving three wound infections and one mechanical intestinal obstruction. There was no intra-abdominal abscess. Conclusion This procedure allows appendectomy by an open classical approach to be performed, and subsequently allows the treatment of the generalized peritonitis by videolaparoscopy, usually without median laparotomy.

Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications

Background: It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. Methods: One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. Results: Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group ( P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA ( P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA ( P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. Conclusions: Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.

Avoiding muscle cutting while extending McBurney's incision: a new surgical concept.

Extending a McBurney's muscle-splitting incision, to achieve a better exposure when performing a difficult appendectomy, by muscle cutting may be associated with an increase in patient morbidity. In a retrospective study we Verified two actual indications that call for wound extension. The first is to correct a malpositioned first incision that does not match an existing anatomical variation in the region of the appendix. The second is to achieve a wide surgical space to deal with complicated cases. For each of these two indications, we thus introduced a new technique that fulfills the real requirement without muscle cutting. For the first indication we used a double muscle-splitting incision, while for the second indication we combined the original muscle-splitting incision with a vertical incision of the posterior lamina of the anterior rectus sheath. The two techniques are herein presented and the results of their application in 126 cases are discussed.

Typhoid enteric perforation.

Perforation of the bowel is the most serious complication of typhoid fever. The role of early limited surgery in managing these patients needs to be assessed. The records of 110 cases of typhoid enteric perforation treated at JLN Hospital, Ajmer between 1990 and 1995 were reviewed. A total of 42.7% of the patients were in the 21-30-year age group, and 83.6% were male. All patients presented with the classic features of typhoid enteric perforation. A total of 83.6% were operated on within 36 h of perforation. Surgical management consisted of primary closure of the perforation (74.5%), closure with omental graft (14.5%), resection and anastomosis (3.6%), and only drainage (7.3%). A total of 79.1% of patients developed wound infection and 10% of patients developed faecal fistula. The overall mortality rate was 16.4%. Increasing the time interval between perforation and operation significantly increased the mortality (P < 0.05). The mortality was least with early primary closure of the perforation. Patients with postoperative faecal fistula had higher mortality rates (P < 0.001). Early limited surgery with thorough peritoneal lavage provides optimal results, faecal fistula is a grave complication, and the use of the McBurney incision may provide better results in terms of subsequent wound healing.

Syndromes and Eponyms

A reader has recently questioned dropping the possessive when referring to conditions described by individuals, that is, Down syndrome vs Down's syndrome. He notes that this practice has made him uncomfortable. Since my mentor regarding this matter was Dr Vaughan, I referred the question on to him and his informative comment follows. "This raises a point of style about which many physicians have strong feelings, which are rooted in the comfort we have in ways in which we first, as medical students, learned about syndromes and eponyms. Medicine has always been inconsistent in this style: we never gave two people possession of a syndrome (Niemann-Pick disease, Smith-Lemli-Opitz syndrome); nor have we always given possessive credit to other innovations (McBurney incision, Trendelenburg position, Charcot joint); nor, in fact, do all syndromes or conditions belong to the person who first described them—some belong to the patient (Christmas disease, Hartnup syndrome). In light of these inconsistences, the style manual of the American Medical Association (Stylebook) in its 1976 revision (6th edition) recommended (page 26) that eponyms no longer be given the possive form. It takes an emotional wrench to make the change, and a little time to get used to it (Wilms tumor, Hodgkin disease), but after a while it flows remarkably easily and comfortably, conserves apostrophes, esses, paper, and space, and often comes to seem eminently reasonable (Vaughan contention). I would be pleased to see the style adopted universally.(V.C.V.

The Mechanisms of Severe Arterial Injury in Surgery of the Hip Joint

Vascular accidents occurring in the course of hip surgery may reach potentially catastrophic dimensions by posing an immediate and sudden threat to life and limb. This is a report of 15 cases with severe arterial injury representing 0.2--0.3% of all reconstructive hip operations performed during an 8 year period. In 6 cases perforation of either the external iliac artery, the common femoral artery of main branches of the lateral and medial circumflex femoral artery were caused by the tip of a narrow-pointed Hohmann retractor used to expose the hip joint. Other mechanisms were: intimal tear with appositional thrombosis, probably caused by mechanical strain imposed on atherosclerotic arteries, giving rise to complete limb ischemia (2 cases); the dangers associated with the entry of bone cement through a defective acetabulum into the pelvis causing thrombotic occlusion due to polymerization heat (one case) or intimate adhesion of artificial bone to the external iliac artery subsequently being ripped open during replacement of the cup (one case); the increased hazards of replacing firmly embedded hip prosthesis (3 cases of direct arterial injury with chisel, knife and cutting edge of protruding bone); and the complications associated with the development of a false aneurysm (2 cases). Fourteen of the 15 extremities were salvaged. Above-knee amputation was unavoidable in one case owing to delay of vascular repair. There was no immediate operative mortality. Knowledge of the causative mechanisms prevents arterial injury during hip surgery. The relatively low rate of vascular complications in spite of vicinity of main vessels gives credit to the well standardized technique of hip surgery, especially hip replacement. However, it is suggested that the surgeon should be sufficiently acquainted with the exposure of the main vessels above and below the groin to be able to control life threatening hemorrhage at all times. A McBurney incision with retroperitoneal exposure and clamping of the external iliac artery will suffice to diminish bleeding considerably. Thereupon careful dissection and placement of snares around the common femoral artery, the arteria profunda femoris, and whenever necessary, the lateral or medial circumflex femoral artery will enable closure of the lacerated artery. For hemorrhage resulting during replacement of firmly embedded hip prosthesis it might become necessary to ligate the internal iliac artery. Reconstruction of obliterated arteries should call for the cooperation of the vascular surgeon for eventual angioplasty. Angiologic examination of the lower extremities is mandatory whenever severe arterial trauma has occurred in the course of hip surgery and is best performed by measuring the ankle blood pressure with a Doppler ultrasound probe.

Acute appendicitis in a child with complete situs inversus

Complete situs inversus occurs once in every 6000 humans.1 Blegenr reviewed 83 patients in the world literature with complete situs inversus who underwent appendectomy, including a child reported from our hospital in 1934 by Drs. Heeks and Eckerson.” The patient was a 12-year-old girl with a 24-hour history of anorexia, vomiting and abdominal pain. Past medical history was normal and she had not reached menarche. Physical examination of the chest was thought to be normal and there was point tenderness to palpation in the left lower quadrant of the abdomen with muscle guarding. Rectal examination was normal. The lymphocyte count was 12,950 with 81 polymorphonuclear leukocytes. There were four to six white blood cells on urinalysis. We elected a short period of observation, but two hours after admission to the hospital her temperature rose from 100.6”F to 103°F by rectum. Abdominal tenderness increased and a diagnosis of acute appendicitis was entertained. The admission chest X-ray showed dextrocardia with the stomach on the right side and the liver shadow on the left. To be certain that a complete situs inversus existed, a low barium enema was performed which confirmed this suspicion. Under general anesthesia the peritoneum was opened through a left McBurney incision and an acutely inflamed appendix was found. During appendectomy a small sealed-off perforation on its anterior surface was unroofed with minimal spillage. The abdominal wall was closed with a single intraperitoneal drain. Penicillin and Streptomycin were given over a four-day period and the drain removed on the fifth day. Nine days after operation the patient ran spiking fevers to 101°F and rectal examination revealed a tender, right sided pelvic mass: With local heat this mass resolved and she went home in good condition 24 days after operation. Dextrocardia coupled with X-ray evidence of a left sided liver shadow, and stomach gas on the right confirms the diagnosis of complete situs inversus in which all internal organs are the mirror image of normal. The barium enema given this patient was unnecessary and could prove dangerous. A review of the English language literature reveals 21 instances of acute appendicitis in patients with complete situs inversus. Sex incidence was equal and ages ranged from 10-46 years; most of the patients were in their twenties. Diagnosis of situs inversus was made before appendectomy in 13 patients. Three patients were in the pediatric group and the correct diagnosis of complete situs inversus and acute appendicitis was made in each child.

Acute appendicitis in senior citizens.

Why is perforation so common in acute appendicitis of the elderly? Delay in seeking medical attention seems to be the main reason. The perforation rate was 68 percent in a series of 44 patients 65 years of age or older. But sound surgical principles-frequent use of the McBurney incision, draining the peritoneal cavity, antibiotics, relieving distention, and controlling fluids-kept the mortality rate low.

The evolution of an ideal surgical incision for pyloric stenosis.

EARLY in the surgical history of congenital pyloric stenosis, the operative approach was involved and often complicated. The infants who were brought to surgery were seriously depleted and many weeks past the age that the diagnosis is made today. Formal laparotomy was the standard procedure through a generous paramedian incision (Fig 1,<i>A</i>).¹Because of the debility of the tiny patient and the less sophisticated replacement therapy, wound dehiscence, evisceration, and death occurred all too frequently. To this distressing clinical problem, Robertson²brought a fresh look when he conceived the right-upper-quadrant, musclesplitting incision. This surgical incision was a counterpart in the upper abdomen of the McBurney incision in the right lower quadrant (Fig 1,<i>B</i>). Recognizing wound healing as a major cause of death in these desperately ill infants, Robertson demonstrated that if the lateral abdominal musculature were split in fiber direction, the external and internal oblique muscles

Spontaneous pneumoperitoneum in appendicitis.

Spontaneous pneumoperitoneum is infrequently encountered as a radiographic finding in association with a perforated appendix. This has led some authors to doubt that it occurs at all (11, 13). A review of the literature revealed a total of 10 cases reported by Vaughan and Singer (14), Guillemin (6), Kornblum (8), Spensley et al. (12), and Epstein (3). In most instances free intraperitoneal gas is a result of perforation of a peptic ulcer. The radiologist should, however, be aware of its occurrence in appendicitis with perforation in order not to mislead the surgeon. The present report describes 2 cases and discusses the pathogenesis as well as the reasons for the low incidence of this complication. Case Reports Case I: J. W. W., a 59-year-old white male, gave a history of abdominal pain, at first periumbilical, then migrating to the left lower quadrant and gradually spreading across the entire lower abdomen. He was first hospitalized and treated with penicillin at a private hospital, where a diagnosis of ruptured peptic ulcer or perforated appendix was made. He appeared acutely ill; blood pressure 120/80. On admission to the VA Hospital, three days after onset, there was tenderness in all quadrants of the abdomen, most pronounced in the right lower quadrant. There was mild rebound tenderness. The bowel sounds were hypoactive. The white cell count was 16,900, with 95 per cent neutrophils; red cell count 4,550,000. Films of the abdomen (Fig. 1) revealed a small amount of free peritoneal air consistent with a perforated viscus. Shortly after admission a diagnosis of ruptured viscus was made, the possibilities of ruptured sigmoid diverticulum, ruptured peptic ulcer, and ruptured appendix being considered. The patient was taken to surgery and a left McBurney's incision was made. On opening the peritoneum, a little air escaped. A large amount of moderately thick, yellowish-brown fluid was aspirated. The sigmoid colon was free of disease. The incision was closed and a right rectus incision was made. The stomach and duodenum appeared normal, but on exploration of the appendiceal area an abscess was found. A necrotic appendix was identified and removed. Culture from the abdominal cavity revealed E. coli. Postoperatively a fecal fistula developed, which gradually improved spontaneously. Case II: B. B., a 56-year-old white male, gave a history of the onset of epigastric pain, which shifted to the right lower quadrant, about three weeks prior to admission. He was at first treated conservatively by a private physician. After about one week he noted a tender mass in the right lower abdomen. There had been frequent attacks of right lower quadrant pain during the preceding year, usually disappearing within twenty-four hours. His blood pressure was 110/60; pulse 90; temperature 100.2°. He appeared chronically ill.

Acute appendicitis in chronically ill geriatric patients

Twenty-one chronically ill substandard risk patients between the ages of sixty and ninety who had acute appendicitis with or without abscess or peritonitis are discussed. They cover a period between 1939 and 1951. The disease is infrequent in geriatric patients and usually serious. Atypical clinical syndromes, difficulty in diagnosis, delayed operation, catharsis and accompanying degenerative disease all contribute to a high mortality. Our mortality rate is 23.8 per cent. Mortality statistics from other sources are also high. Peritonitis, pneumonia, cardiac failure and thrombosis have been among the leading causes of death in several autopsies. Suggestions are made to help reduce mortalities. The pathology is discussed. Microscopic studies were made of the appendices in the acute conditions and of others removed in autopsies on patients sixty and over who died of causes other than acute appendicitis. The observations suggested that early massive gangrene might result from diminution or absence of lymphoid follicles in the wall of the appendix, sclerosis of the vessels supplying it, obstruction in its lumen and previous damage to the appendix by inflammation. It is significant that all the eleven patients who had acute appendicitis without perforation survived after appendectomy. We do not subscribe to the so-called conservative therapy as a routine in which the appendix is not removed or in which abscesses or peritonitis are not drained. Antibiotic therapy has supplemental rather than substitutional value for surgery. Appendectomy is indicated except in those cases in which technical difficulty would prolong the operative time to such an extent that the hazard to life would be markedly increased or when additional trauma would be instrumental in further spread of infection. Generally, the McBurney incision is the most preferable.

APPENDICITIS

IN TWO previous reports from this clinic, all cases of patients with appendicitis admitted to the Cincinnati General Hospital between 1915 and 1934 1 and 1934 and 1939 2 respectively were reviewed. The present study is a continuation of this series and will include all cases of patients with appendicitis treated between Jan. 1, 1939 and Jan. 1, 1944. In the preceding articles the general trend toward a reduced mortality rate from appendicitis as seen in this hospital was noted. This favorable trend was attributed to (1) the adoption of the McBurney incision in 1922 for appendectomy and (2) the intensive educational campaign concerning management of appendicitis directed toward physicians and the public. This campaign, fostered by the Public Health Federation and the Academy of Medicine of Cincinnati, is still in progress. The sustained and commendable improvement resulting from the campaign may be gaged by a comparison of certain phases

Acute appendicitis: An analysis of 417 consecutive cases

A statistical analysis of 417 consecutive cases of proved acute appendicitis is made. The distribution in sex, color and age groups is stated. An outline of the usual method of treatment is given. The signs, symptoms, temperature, pulse, respiration, duration of symptoms and use of cathartics are analyzed. At operation the McBurney incision is used almost exclusively when the diagnosis is certain. When drainage is employed, the tendency is to suture the peritoneum only. Wound infections, bacteriology and complications are presented. There were fourteen deaths or an incidence of 3.3 per cent in the entire series. There were no deaths in 300 unruptured cases; ten deaths out of seventy or an incidence of 14.2 per cent in the group with spreading peritonitis and four out of fortyseven or an incidence of 8.5 per cent in the group with abscess. A brief report of each case in which death occurred is given.

The value of varying the position of the McBurney incision

In the performance of an appendectomy the muscle splitting incision should be centered over the point of maximum tenderness. This point corresponds to the base of the appendix and an incision at this point gives better exposure than the classical McBurney incision.

Acute appendicitis in children

Two hundred ninety-three children suffering from acute appendicitis have been analyzed. Five deaths occurred in this group, two of which were nonoperative. This is a marked reduction in death rate as compared to previous reports from the same service. Among the outstanding reasons assigned for the lowered mortality rate are: (1) earlier hospitalization; (2) fewer cathartics; (3) more preoperative care aimed at correcting fluid balance, especially in toxic dehydrated patients with evidence of spreading peritonitis; (4) better anesthesia and (5) the use of the McBurney incision. This incision is likewise believed to have been the chief factor in reducing hospital stay from twenty-one days in the previous report to fifteen and six-tenth days in this series. Further followup observations in cases in which drainage was employed and in which only the peritoneum was sutured is reported, with a decreased incidence of hernia in this group.

The right lateral rectus incision in acute appendicitis

In recent years the McBurney incision for appendectomy has been recommended highly. Its advantages are unquestioned but its disadvantages suggest themselves when the advantages of the right lateral rectus incision are considered especially in acute cases which may have developed complications. Moreover in those acute cases in which the diagnosis is not completely clear and in those so-called chronic cases in which some exploration may be desirable at operation, these advantages become even more apparent. The right lateral rectus incision is more directly over the site of the appendix, the meso-appendix and localized complications. The incision avoids damage to anatomical structures; it lends itself to extension readily in either direction; it permits a firm closure even when drainage has to be employed and it facilitates the operative procedure.

Acute appendicitis: A comparative survey with remarks on its management

Certain conclusions may be drawn from this mass of information. 1. 1. The operative mortality for acute appendicitis at this hospital, under a regime of radical treatment as practiced by a sizeable group of surgeons employing varied techniques, was 4.2 per cent during the year 1934–1935. This represents a marked reduction in the mortality of five years previously. While this mortality in no sense is comparable to that reported by certain clinics, better hospitals, and in various individual series, it nevertheless represents a rather respectable effort to cope with a problem of increasing difficulty. 2. 2. Inadequate hospital records prevented an evaluation of the importance which the factors of time and cathartics may have played in effecting this lowered mortality, but it is certain that better surgical judgment and improved surgery were largely instrumental in producing the marked drop in mortality which occurred in the group of cases complicated by peritonitis. 3. 3. The mortality in acute uncomplicated appendicitis at this institution is creditable and probably almost irreducible, but the treatment of appendicitis with abscess still shows a mortality which is much too high. 4. 4. A short experience with bacteriophage as an adjuvant in the treatment of ruptured appendicitis is reported. No apology is made for the brevity of the series since the cases are considered to be representative. However, it is appreciated that only through triai in a reasonably long series of cases can a true estimate of its value be reached. It is likely that no one operative procedure will effect a very material drop in mortality among the severe cases of appendicitis. Improved mortality in all probability will result largely from the exercise of better judgment as to when to operate and how much to do. However, three points in operative procedure do stand out as worthy of particular consideration in any plan for reducing operative mortality in appendicitis. 1. 1. The weight of evidence seems to indicate that in the very small percentage of cases where a severe spreading peritonitis complicates the picture, a regime of conservative treatment and temporary delay in operation offers the patient the best chance of.recovery. 2. 2. Controlled series seem to show that the use of the McBurney incision or its modifications favors a lowered mortality by confining operative manipulations to a very limited area of the abdomen, thus helping to keep the peritoneal infection localized. 3. 3. In an admittedly short series of cases, bacteriophage has shown that it is worthy of further investigation in the treatment of cases complicated by peritonitis. The experience has been that improvement in the hospital management of acute appendicitis is capable of producing a marked lowering in the mortality rate of this disease. It appears probable, however, that any considerable mortality drop will occur only when the public is thoroughly enlightened regarding the dangers of catharsis and of procrastination in the treatment of abdominal pain, and when routine early hospitalization of these cases will make possible removal of the appendix at a time when the operation carries with it, in experienced hands, a mortality which is almost negligible.

Ventral position for drainage in ruptured appendicitis

U R PTURED appendicitis is a treacherous disease and events occur rapidIy when once pus invades the peritonea1 cavity. There is no other pIace in the body where Nature acts so speediIy and with such force, where toxins are absorbed so readiIy and where great amounts of pus can accumuIate so quickly. Therefore, the treatment in these cases shouId be directed to early evacuation of the pus and detoxification of the patient. It is beIieved that this can be much more satisfactorily accomplished by the ventra1 position than by the FowIer position. In May, 1930, the senior author reported a series of 108 drainage cases with a mortaIity rate of 12 per cent. In January, 1928, he began using the ventra1 position and technique routineIy as herein described. In October, 1930, he reported 37 cases with a mortaIity of 2.7 per cent. We have now treated 80 drainage cases with 6 deaths and with a corrected mortaIity of 3.8 per cent. Immediate operation through a routine McBurney incision is advocated in practicaIIy a11 cases. The appendix is found and removed with as IittIe manipulation and trauma as possible. When necessary the area around the appendix is cofferdammed with gauze. The pus is aspirated as it comes into view. Catgut sutures are used throughout. If possible the stump of the appendix is aIways inverted. The aspirator is then pIaced aIong the brim of the peIvis, following the finger as a guide to the bottom of the pelvis. This area is thoroughIy aspirated and upon removing the aspirator a cigarette drain, one-haIf inch in diameter, is placed in the peIvis foIIowing the path of the aspirator. A smaI1 drain, either of gauze or rubber tubing, is placed at the stump of the appendix. AI1 hemorrhage is controhed and the wound cIosed IooseIy about the drains. It is important to anchor the drain and to cut it off even with the skin so that it wiI1 not be driven against the peIvic floor when the patient assumes the ventraI position. As indicated in the accompanying cut, the position is simpIe. It is assumed immediateIy upon returning the patient to the room. The patient is pIaced upon the abdomen with the face turned to the Ieft, the Ieft arm is flexed at the eIbow, whiIe the right is pIaced paraIIe1 to the body. The Ieft Ieg is sIightIy Aexed, and the right remains straight. The head of the bed is eIevated 8 inches. The patient maintains this position from thirty-six to forty-two hours, depending upon the amount of drainage and severity of the case, but at intervaIs may be turned on the right side for rest and for catheterization. A piIIow pIaced under the chest but not under the head frequentIy adds greatIy to the comfort of the patient. After thirty-six to forty-two hours the patient is permitted to Iie upon the back, but encouraged to spend as much time as possible on the right side. The reasons for the ventra1 position are obvious. It pIaces the incision at the Iowest point of the abdomen, and the drain keeps an open pathway to the depth of the peIvis, providing actua1 and immediate drainage. The advantage is obtained aIso of both intra-abdominal pressure and gravity in drainage and the pus is discharged instead of being pooIed in the abdomen, depending upon capiIIary attraction to remove it. The average period of iIlness in this series of cases before operation was 3.3 days. The average Ieucocyte count was 16,500. Norma1 temperature was regained in 6.9 days, and the average stay in the hospital was 17.1 days. On discharge there were 4 wounds stiI1 draining pus; rg had heaIed; in 56 drainage had ceased and the wounds were granmating, and I showed deIayed heaIing.