The more common congenital anomalies of the various divisions of the colon have to do mainly with the presence of diverticula and atresiæ, or possibly total absence, due to defects in development. Diverticula are much the more common. Some degree of constriction is not particularly infrequent, but complete absence of even a section of the colon is an extremely rare anomaly.

The acquired anomalies have to do with disease processes or results of injury. Displacements may be the result of old adhesions and distortions; of chronic constipation, i. e., fecal impaction and resulting overloading, with sagging, stretching, and complete change in shape and position; with displacement due to enlargement of other organs, e. g., the liver, stomach, spleen, uterus, or, in milder degree, with the gradual but inevitable and chronic results of tight lacing. The causes which produce a gradual enteroptosis of the transverse colon are not supposed to concern the surgeon, yet the condition may precipitate acute obstruction which will necessitate his urgent participation in its final treatment.

There are no diseases peculiar to the large which do not also concern the small intestine, and no surgical diseases peculiar to it which have not been considered in the foregoing pages. It is not, therefore, necessary to make even a brief summary of the surgical diseases peculiar to the large intestine. Of well-known lesions, however, in this location there is perhaps a little worth emphasis in this place. The most serious surgical conditions of the large bowel, aside from the acutely obstructive, are those pertaining to expressions of tuberculosis, syphilis, actinomycosis, dysentery in one or other of its tropical forms, and cancer. There is a condition also of either acute or chronic colitis or mucocolitis which may assume such extreme degree as to necessitate a colostomy made at the cecum (appendicostomy) for the purpose of more perfect irrigation and physiological rest. The amount of suffering, as well as of toxemia, which may proceed from a seriously inflamed colonic mucosa, must be at least once seen in order to be fully appreciated. Such a condition is characterized by local and general suffering, with septic and copremic symptoms, as well as by tenesmus and the passage of numerous small or larger and more infrequent amounts of blood-stained mucus, sometimes of almost pure blood. As an illustration if one recall what may be seen in case of a violently inflamed conjunctiva or pharyngeal mucous membrane, and realize that this condition is duplicated through a large portion of the colon, a more vivid picture of what it actually represents can be afforded. When exposed to inspection, as it may be when the rectum and the sigmoid are involved, it will be found to bleed at the slightest touch and to freely discharge large quantities of thick mucus. While such a colitis is usually treated by non-operative methods an anesthetic is sometimes required for its more perfect diagnosis and recognition, as well as for such local applications as can scarcely be made without it.

TUBERCULOUS AND SYPHILITIC ULCERATIONS OF THE COLON.

Tuberculous and syphilitic ulcerations of the colon may be localized and relatively insignificant, or numerous, disseminated, extensive, and serious. In extreme cases of this kind the entire colonic mucosa will be involved and the amount of distress thus occasioned be scarcely controllable. These are the cases which, failing to yield to ordinary therapeutic measures, justify colostomy at the cecum, for the purpose of temporary exclusion of the large intestine and its physiological rest, as well as its more perfect local treatment by the irrigation and suitable local applications thus permitted.

STRICTURES OF THE LARGE INTESTINE.

Strictures of the large bowel have the same etiology as those of the small bowel, and are to be recognized by the same general indications, of which increasing obstipation, perhaps with alternating attacks of diarrhea and increasing difficulty in evacuation, are unmistakable features. The nature of a stricture is not always to be foretold before the exploration which it will necessitate. No stricture of the large intestine which is above easy reach from the anus can be successfully treated by any save operative methods, i. e., by abdominal section and proper attention to whatever may be thereby revealed. Thus at one time bands may be divided or some external mass removed by pressing upon the bowel (e. g., a uterine myoma), or there may be found an associated tumor, malignant or benign, whose complete removal is both possible and permissible, or at other times a malignant stricture so complicated that only an entero-anastomosis, for temporary relief, can be effected.

CANCER OF THE LARGE INTESTINE.

Cancer of the large intestine spares no part of its length or lumen. Primary cancer of the cecum may commence in the region of the appendix, and has frequently been mistaken for a chronic appendicitis. If the transverse bowel be involved there may be more or less sagging or fixation, while at the flexures obstruction is more easily produced. Such growths in time become sufficiently prominent to be easily recognized from without, but then they have usually gone beyond the time when radical operation can hold out much promise. In the large, as in the small, intestine radical operations are, however, often successful, and always in proportion as they are made early and thoroughly. When extirpation is impossible anastomosis will offer a temporary substitute ([Fig. 589]).

Fig. 589