holding the knife with its blade perpendicular to the skin surface. This was done with the idea of fashioning a skin graft which should so overlap as to prevent the peculiar keloid-like overgrowth of the scar, which is frequently observed. This skin graft incision, if we may use the term, is best executed by means of a knife having a hollow ground blade, with the handle so adjusted that the edge of the blade occupies a lower plane than the lower surface of the handle when the knife is in position.

First making the skin tense with the left hand, a U-shaped incision starts just at the upper limit of the hair line, on the patient's left side, about seven centimetres from the center, and is carried down to a point just over the pubic symphisis, going across and up, in a corresponding manner on the right side.

In making this incision the blade of the knife is held with its flat surface nearly parallel with the skin surface in such a manner as to cut a graft at least one-half, or better, three-quarters of an inch in width before the edge of the blade penetrates the deepest layer of the skin. It is not necessary that the entire depth of the skin graft incision should be made at one stroke of the knife, for if the portion of the flap already formed is turned back by a gauze wiper held in the left hand, the entire incision can be gone over again and again until the proper depth is attained.

As soon as the skin has been cut through in this manner, the razor-bladed knife is discarded, the raw surface of the incision is thoroughly wiped with sterile absorbent gauze, after which the operation is completed with the ordinary scalpel. As the incision is deepened, going perpendicularly now through the fat to the fascia of the external oblique, throughout the entire length of the wound, quite a number of blood vessels are encountered, far more than in making the ordinary central incision; if these are clamped, however, the hemorrhage is promptly arrested and rarely does one need to ligate. In order to expose thoroughly the fibres of the external oblique, it is best to wipe the depth of the wound vigorously with a moist gauze wiper, thus freeing the fascia of fat, which otherwise obscures one's view of the glistening fibres.

The fascia having been freely exposed and bared of fat, an incision is made in the center of the wound, extending transversely through the anterior sheath of the recti muscles about an inch and a half above the superior pubic border.

As soon as this incision reveals the perpendicular fibres of the recti, or the somewhat oblique fibres of the pyramidalis, the knife may be discarded and the rest of the fascial separation completed with blunt-pointed scissors. This separation consists in extending this transverse incision outward until the interlacing fibres of the anterior sheath of the rectus give place to the well defined oblique fibres of the fascia of the external oblique, parallel to, but considerably above Poupart's ligament. When this has been ac

complished the scissors separate the fibres of the external oblique parallel to their course nearly up to the angles of the wound on either side. As this is done these fibres retract slightly, revealing the more transverse and more muscular fibres of the internal oblique, which are separated in exactly the same manner, and strictly parallel to their course.

All of this is done without the least difficulty, and without severing a blood vessel of noticeable size. The operator now grasps with vulcellum forceps the upper edge of the incised rectus sheath exactly in the center; this forcep remains in place throughout the operation, and serves not only as a handle for the flap, but also as a landmark of its center, and to prevent a tendency of the flap to infold at a later stage in the operation.

As the attempt is made to lift this flap it will be found that while it has hardly any attachment to the rectus muscle itself, being easily separated by the fingers, it is very firmly attached to the space between the recti by a fair amount of fibrous tissue, which requires free incision with the scalpel, holding the instrument so that its edge is directed toward the muscle rather than toward the fascia. By lifting on the vulcellum and continuing the dissection upward, a flap is soon raised which exposes the recti for four, five or even six inches of their length.

This process not only exposes the entire width of the recti, but also the space to their outer sides, which is occupied by delicate fascia and fat only. As the tension on the flap increases it is found that the resistance is produced by the fibres of the internal oblique, and it is necessary to split them still farther outward underneath the lateral margins of the wound. The scalpel is now used to start a separation between the recti high up in the wound. This separation extends downward, exactly in the median line to the apex of the pyramidalis; it then cuts a very delicate fascia which connects the right pyramidalis with the right rectus, lying upon a slightly deeper plane. It is probably immaterial whether this divergence of the incision is turned toward the right or the left side; the right side has been chosen, however, with the thought that we would thus gain a slight advantage in reaching the appendix.

The peritoneum is opened with the usual precautions, and the bladder is carefully protected while extending the peritoneal in

cision.

We find by experience that the opening attained in this manner gives us ample room for the execution of ordinary pelvic operations. It will probably permit any pelvic operation except the removal of the enormous fibroids, which fortunately we but rarely meet nowadays.

The incision is closed by suturing the peritoneum with a very ĥne continuous catgut suture, using only a few stitches and draw

ing the thread tight enough to pucker the membrane considerably. The recti are caught together by one or possibly two delicate catgut stitches after the wound is carefully inspected to be sure that no bleeding points are left; but no water is used, nor is the wound unnecessarily wiped. The entire flap is now turned down, care being taken that the vulcellum for holding it is held exactly in the central line of the body. Now with a very fine catgut suture of good length we start on the left side to suture accurately and delicately the fibres of the external and internal oblique, and the anterior sheath of the rectus in exactly their proper relations. Starting on the left side, the needle passes through the lower edge of the external oblique, the lower edge of the internal oblique, the end of the thread being held to prevent its drawing through, from this point inward to near the median line the needle pierces the edges of the internal oblique only, forming an over and over stitch.

Near the median line the fascia of the external and internal oblique blend so intimately that they are indistinguishable; here the needle takes up the edge of both structures, but the stitches are twice as far apart as when only one structure is involved.

Having passed the central line in its course toward the right angle of the wound, the suture again involves the internal oblique only, until the last stitch at the angle comes up through the upper edge of the external oblique. The same thread is now carried back from right to left, making over and over stitches through the edges of the external oblique until near the median line the blended fascicae are again encountered, where the stitch again involves both structures; each stitch at this point is twice as long and is placed exactly between the first line of sutures. Passing farther toward the left, the suture again involves the external oblique edges only and at the outer angle of the wound is tied to the initial stitch, the end of which we left long. In this manner the flap is held down firmly, and yet the tension is so slight and the structure so delicate that a good quality of No. 1 catgut gives ample strength.

The deeper portion of the fat layer is now closed by very long stitches of No. 1 catgut in exactly the same manner, beginning at the left and below, leaving the thread long and ending at the right above, very near the junction of the skin and fat. In returning to the left angle of the wound this stitch is carried back and forth just underneath the skin, at the junction of the skin and fat. and when it has reached the left angle tied with only moderate tightness to the long end of the initial stitch.

In this way the wound is closed except the skin graft which was described earlier in this paper. The immediate field of operation is now cleansed of blood stains and wiped dry, and the skin graft is fastened in place by means of a dozen or more strips of sterilized court plaster. Each strip is about an inch and a half

in length, and a quarter of an inch in width, and is applied by first laying half of it onto the skin graft, to which it adheres instantly; then lifting up on the free end of the plaster strip, the very edge of the skin graft is wiped flat onto the plaster, and by drawing down slightly on the strip the edge is adjusted accurately to the point from which it was cut. The space left between each strip is about a quarter of an inch. and following this manipulation there is usually a very slight exudate of bloody serum, which is absorbed by pressing onto the wound a dry wiper. If now the wound is left exposed to the air, this very slight exudate of serum forms a crust which has so far in our experience proven an effective protection against infection, and we have therefore abandoned the use of any dressing whatever.

I do not wish to maintain that my experience has, as yet, been wide enough to make positive the statement that a dressing should not be used under any circumstances; I merely record the fact that in thirty-seven cases there has been only one case of infection and that in a patient with a very marked purulent cystitis, in which it is believed that my own manipulations infected the abdominal incision. I find that in from four to seven days healing is complete, and the plaster strips can be removed without pain and without wetting them. The wound is at all times in plain view, and should any evidence of infection appear there would be no excuse for allowing it to extend. It must not be forgotten in the after treatment of this incision that exposure to the air is essential in order that drying of the wound may take place as promptly as possible.

Conclusions: The central incision in the lower abdominal wall is anatomically very imperfect and the arrangement of muscles is such as to place greater strain upon this structure than upon any other portion of the wall, not only during the healing process but forever afterward.

The transverse semi-circular incision is executed with greater difficulty than the straight central incision and is less capable of extension, but it gives an opening of four or four and a half inches or more in length, which provides easy access to the lower half of the abdomen and the pelvis.

For the prevention of ventral hernia it is as superior to the central incision as is the McBurney incision to the old-fashioned direct incision for reaching the appendix.

It permits the use of a smaller-sized catgut and therefore tends less toward infection.

Having purposely allowed patients to vomit during the operation we are positive that even with the finest catgut the wound will not give way.

The incision is, in most cases, entirely hidden in the pubic hair. The skin graft incision is more or less difficult to execute and requires a special knife.

Its advantages are that it requires no suture and no dressing, and that the resulting scar bids fair to be practically imperceptible. Thorough ventilation of the wound is necessary, and if this is provided healing by primary union is the result.

DISCUSSION.

DR. MARTIN:-I regret that I was not privileged to read this paper before being called upon to discuss it. I am no better prepared to diseuss the paper than any one of you, but Dr. Roberts has apologized so kindly that I cannot criticise him.

It was my privilege last spring to see Dr. Roberts do some abdominal work, using this incision. If I remember aright, he did not at that time use the skin graft incision. This question of the transverse incision for entering the lower abdomen and the pelvis was first prominently called to the attention of physicians in this part of the country, I think, by Stimson, of New York, in a review of about a hundred and fifty cases published in the "Annals of Surgery" about two years ago, and there have been several articles upon the question since then which have happened to come to my notice. I had never tried in my own work this cross incision until I saw the work of Dr. Roberts. Since then I have given it a considerable test, and must say that it appeals to me very strongly.

The object in view in making the incision should be, not alone the exposure of the field for your work, but making the incision in such a way as to protect your work, and allow the least danger of hernia. This incision applies the old principle of the cross layers and is really only the amplification of the well known McBurney work over the appendiceal area. You know the thin, wooden chair seats that possess so much strength are made up in layers crossing and re-crossing, and that is the principle that the Allwise has applied in building up the abdominal wall. I think the strongest point made for the value of this incision is the fact that after the work is finished we do not have the lateral pull upon the central structures, the whole length, at least, of our wound, that we do have when the incision is made perpendicular through all the lavers. We all have given up practically making a single incision straight down through the alternating layers of muscle and fascia over the appendix, and the majority of surgeons have adopted the layer incision. It seems to me the same principle applies here. I have found in the little work it has been my privilege to do by this method, that the pelvis at least is better exposed by an incision of equal length through or between the recti muscles. This method, I believe, adds materially to the working room which the surgeon has in the lower abdomen and in the pelvis.

The skin graft feature I am not prepared to say anything upon. I cannot forsake my training and my experience in the importance of protecting wounds, to the extent of leaving my patient's wounds entirely uncovered. I think it will take perhaps a few years to bring me to that point, but I must confess that feature of his work does not at first sight appeal to me. His double layer of running sutures is interesting. The plaster method of closing the wound is interesting too, and we have applied it to the ordinary incisions, though I have never seen it applied to this oblique incision.

One point in which I have found a slight objection in this work: After stripping back the fat and fascia after this original incision is made you necessarily sever a good many of the nourishing vessels which go through the layers. One great trial we have had in getting good primary results in our abdominal work has been the after nourishment of this layer of fat, and where we have failed to get a good. clean first intention, it has often been from the softening or breaking