This affords the means of irrigating the entire colon from the cecum to the rectum. A solution of one per cent. nitrate of silver followed by a saline solution is commonly used for irrigating. Solutions of Kramer, witch-hazel, peroxide of hydrogen, or plain water are valuable substitutes for irrigation

Fig. 18. Gibbon’s valvular colostomy   last tier of sutures.

Fig. 18. Gibbon’s valvular colostomy - last tier of sutures.

The operation does not turn the fecal current aside and affords a method of lessening the irritation existing during the course of any of these colonic diseases. The operation is practically without danger. A small fecal fistula will close spontaneously it not kept open by the use of the catheter; should it not close of itself it can be easily dissected out under cocaine anesthesia and closed by sutures.

Appendicitis The operation for appendicitis may be performed by any of the modern preliminary methods of technique for appendectomy, but the gridiron or muscle splitting method probably ensures a more healthy and secure procedure for the protruded appendix. The following method is therefore suggested: A skin incision is made over MC- Burney’s point, one and one-half inches inside from the anterior superior spine of the ilium, on a line drawn from that point to the umbilicus. This incision should be from two to three inches long through the skin. The fascia and muscles are split in the direction of the fibers of the external oblique; the separation should be large enough to admit the introduction of two fingers to find the appendix and lift it out through the incision.

Fig. 19. Gibbon’s method, showing result of infolding gut.

Fig. 19. Gibbon’s method, showing result of infolding gut.

The cecum may have to be drawn upwards to free any adhesion to the appendix. Should this be necessary the condition of the cecum should be noted, and returned, if its condition does not warrant colostomy\. Two fine silk or chronic gut sutures are passed through the skin and parietal peritoneum, then the appendix is transfixed through its muscular coat near its base, then tied; another suture is passed through the skin of the other side and the process repeated. The incision on both sides of the protruding appendix is closed by layers of sutures in the ordinary way. The appendix should be amputated about one-half of an inch from the skin and any bleeding temporarily controlled. A number 10 soft rubber catheter of the English Scale may be passed into the cecum for about three-quarters of its length. Should it be deemed advisable, or necessary to irrigate the bowel at once the free end of the catheter may be connected with an irrigation containing a saline solution at about 100° F. The quantity of this solution may be as great as several pints and the procedure so thorough as to wash the entire large bowel before the patient leaves the operating table. Further irrigation may be carried on continuously after the patient is put back to bed and the colon washed freely with a warm physiological salt solution for several hours if necessary.

Subsequently, as the symptoms improve and as necessity dictates, a plug devised to keep the opening patent and prevent leakage may be introduced.

When it is desirous to close the wound the stump may be freed from the surrounding tissue and ligatures introduced preserving the blood vessels. so as to oversee the aperture. The stump is then allowed to drop back into the abdomen and the skin wound closed. In some instances touching the exposed mucous membrane with the actual cattery is all that is necessary to close the appendix.

Unfortunately some cases do not present this favorable course of treatment and owing to either an atrophy of the stump or constriction of the appendix will bring about a complexity of symptoms. Such complications have caused the advocates of Valvoline to feel assured of the correctness of their views.

To offset the atrophy of the appendix the normal blood supply should be maintained. The blood vessels are contained within the layers of the mes-appendix which should not be removed, nor even injured during the manipulation of the appendix.

Fig. 20. Appendicitis, showing cecum and appendix lifted Up with dysentery,

Fig. 20. Appendicitis, showing cecum and appendix lifted Up with dysentery,