Cancer of cecum, showing ulcerating growth protruding interiorly and obstructing. (Dr. E. A. Smith.)
OBSTRUCTION OF THE LARGE INTESTINE.
Chronic obstruction of the large bowel is usually due to one of the causes above considered. Acute obstruction of the colon is the result either of precipitation of an acute condition upon the base of an old chronic trouble, of invagination, of volvulus, or possibly of one of the other mechanical contortions not included in either of these expressions.
Intussusception is most likely to occur either at the ileocecal valve or in the region of the sigmoid. Volvulus is more common in the latter region. It is here due to relaxation of natural ligamentous supports, to overloading and stretching, or is possibly permitted by some congenital condition. Volvulus in this section having once occurred the patient is liable to its subsequent recurrence. So well known now is this fact that surgeons have endeavored to take special precautions against it, which unfortunately have not been brilliantly successful. It has been suggested, for example, to anchor the sigmoid to the anterior abdominal wall, or to resect a portion of it, to anastomose it with the cecum, as well as to reef the mesosigmoid. Desirable as such operative relief may be, all of these methods present inherent objections, while those which include absolute fixation of the sigmoid perhaps predispose it to subsequent obstruction from other causes. At present it would appear that a sigmoidopexy is probably the best procedure, in order to prevent local recurrence, in a sigmoid volvulus which has once been exposed by operation, care being taken to fasten it well up to its outer side, as well as posteriorly, in order that there may be no vacant spaces in these directions.
THE RECTUM.
GENERAL CONSIDERATIONS.
The rectum was for too long a time relegated to the care and almost sole interest of the itinerant charlatan, or the somewhat ambitious, though scarcely more honest, specialist, who preyed alike upon the suffering and ignorance of patients, until the practice of rectal surgery was almost a mark of disgrace. From this unfortunate condition it was rescued by the organized effort of honest men, until now, in the light of their researches, the rectum has been shown to be both the site of numerous, easily discernible, and serious, alike mysterious and reflex lesions, all deserving careful study. The connection between the sensory nerves with which its terminal inch and a half are freely endowed and the vasomotor nerves throughout the body is easily shown by their influence, for instance, upon the respiration and the circulation, and in these respects some important lessons have been learned from the charlatans. We have learned, for example, that general vasomotor spasm, with its evidence in coldness of the extremities and pallor of the surface, may often be overcome by so simple a measure as stretching the sphincter; while to cure lesions which produce more or less sphincteric spasm is to frequently restore general circulatory tone. Again, what may be accomplished in stimulating respiration by dilatation of the sphincter has been shown to be of the greatest value in patients breathing badly under an anesthetic.
The “orificialists,” then, while making absurd and impossible claims, have nevertheless taught us considerable concerning the value of recognizing the importance of sphincteric spasm. Their claims concerning so-called “pockets” and “papillæ” are untenable and absurd, and the expression which they have taught many of the laity that they are sufferers from “rectal pathology” indicates alike their ignorance of good English and good surgery. That papillæ do become, under certain circumstances, exquisitely sensitive and are occasionally in need of the cautery or the scissors, as well as of the general relief afforded by stretching the sphincter, is undoubtedly sometimes true.
The itinerant “pile-drivers” and charlatans of their class have done more harm than good, and yet even from them the honest practitioner has learned that “it pays” often to give attention to the rectum. As a source of various disturbing and particularly distressing reflexes there is scarcely any portion of the body of equivalent area which can furnish so many. The relief to mental conditions, amounting often to pronounced melancholia, which follows cure of rectal lesions, is often astonishing, all of which shows that the rectum is well worth the attention of the scientist, and especially of investigation in every case where the slightest complaint is made.