One source of doubt and disappointment is met occasionally in the radical treatment which requires division of the sphincter, for to completely divide this muscle is to practically paralyze it and leave the patient thereafter with fecal incontinence more or less marked. Such accidents leave more or less disabling consequences. Usually they are avoidable, for it is rarely necessary to cut completely through a sphincter muscle, it being possible to avoid the necessity by partial division, with perhaps more complete exposure above and below. Even in those instances where it seems unavoidable if the muscle be first vigorously stretched, and thus temporarily paralyzed, it may then be safely divided, provided it be neatly and completely sutured at once, and the parts kept at rest for a few days, the intent in stretching the muscle being partly to so weaken it that it shall be temporarily disabled. It was suggested years ago by Jenks, of Detroit, and later by Kelly and others, to make a complete excision of the entire fistulous tract and then to treat this as any other fresh wound, closing it completely with sutures. The method is good in theory and occasionally applicable, and should not be neglected when circumstances favor its practice.

Every fistulous tract, simple or complicated, not promptly and neatly closed, should be dressed with gauze, with or without yeast, balsam, or some one of the other local applications recommended elsewhere in this work.

PROLAPSE, PROCIDENTIA, AND INVAGINATION OF THE RECTUM.

Prolapse of the rectum is observed in two degrees, either as a mere eversion of its mucosa, which, however, may be profuse and extreme, or as an actual escape by process of invagination through the anus of some portion of the rectal tube, with all its coats, including in well-marked cases even its peritoneal covering. The former is more common in children as the result of diarrhea, colitis, the presence of pin-worms, or other parasites, or any other cause which produces tenesmus and frequent straining, with consequent relaxation of the anal sphincter. It is amenable to treatment and is usually of insignificant proportion. It is also frequently seen in adults in connection with internal hemorrhoids, which are extruded with every stool, carrying with them more or less mucosa, and which are usually returned within the rectum by the patient at the conclusion of the act of defecation.

The more complete form of prolapse by true invagination is rarely seen, save in adults, and in consequence of some serious preëxistent condition, such perhaps as complete laceration of the perineum in the female, paralysis of the sphincter from previous accident, or from the existence of spinal-cord disease. Here and in extreme cases several inches of bowel may be extruded from the anus, and to an extent scarcely permitting spontaneous or even individual restoration. So complete a form is permitted only by some previous lesion of the pelvic floor, while the mesorectum and even the mesosigmoid become gradually stretched and useless. The lower portion of the rectum is by far the more muscular, and such a condition requires that its intrinsic muscles yield also with those around them.

Prolapse is a condition of general and usually slow development rather than of abrupt onset. It is made known by the presentation at the anus of the bright-red mucosa of the rectum, where it pouts and protrudes, forming a tumor of varying size, with more or less tender surface, which, with gentle coaxing pressure, is easily made to return within the rectum. It can usually be made to appear by straining effort on the part of the patient. Boys with phimosis, who are in consequence made to strain every time they urinate, will frequently present minor degrees of the condition, perhaps oftener than when the rectum itself is at fault, as the act is so frequently repeated. The oftener such protrusion occurs the more relaxed becomes the anus and the more irritated the presenting surface, until ulceration and even keratosis may result. Chronic constipation of children or adults will also produce the same effect. The presence of hemorrhoidal tumors or of polypi, or even of parasites, causes the same result.

The most pronounced and complete types of invagination produce a condition in which reduction is perhaps not possible and procidentia is constant. There may form here a pouch around the rectum, containing loops of bowel, bladder, or ovary, or there may even occur a perirectal hernia.

While patients nearly always become more or less accustomed to the condition it nevertheless is distressing in proportion to its size and the individual’s temperament.

Treatment.

—Treatment depends entirely upon the nature and extent of the condition. Mild forms occurring in young children may be easily obviated by attention to their stools, by circumcision if needed, or by the use of a five-grain capsule of ergotin inserted as a suppository, it having the effect of invigorating the involuntary muscle and stimulating the sphincter. Cases not amenable to the milder methods become surgical and the treatment is then apportioned to the extent of the lesion. If connected with hemorrhoids or other tumors it becomes a part of their treatment and is to be dealt with at the same time. Occurring apparently independently the milder forms will often yield to the proper use of caustics. The actual cautery being preferable, it is applied in streaks up and around the rectum, in such a way that, when the ulcers thus formed cicatrize, the rectum shall be shortened by cicatricial contraction as by a series of loops drawn up to shorten it. When permitted by rupture of the perineum and more or less combined perhaps with cystocele, repair of the perineum, rather than attention to the rectal condition itself, will be demanded, while the latter may be combined with an operation for rectocele by excision of an elliptical portion of the vaginal mucosa and the approximation of its edges into a line of sutures. This will reduce the capacity of both the vagina and the rectum and a double indication be thus met. Acute inflammation sometimes follows exposure of a prolapsed rectum and it may slough, thus leading to spontaneous recovery, the process not being without its dangers of thrombosis and septic infection. This procedure may be imitated by a surgical excision of the entire prolapsed portion, always with great caution so that if peritoneal surfaces be exposed they be protected from infection. It has been possible in many instances to completely excise the protruding portion, and then to apply a double row of sutures similar to those used in intestinal resection, only with attention first to the peritoneal rather than the mucous surface, in such a way as to excise several inches of the prolapsed bowel and thus meet the indication. Nevertheless cases where this can be done are exceptional.

Pratt has suggested a temporary purse-string suture of the anus, effected by a curved needle, completely circumscribing the anal opening, but kept between the skin and the mucous membrane, to be brought out through the same puncture at which it was inserted. The finger of an assistant being passed into the anus, the suture is now tied around it. This may be used as supplementary to linear cauterization above mentioned.

Numerous methods of proctopexy, or elevation and fixation, have been devised. Fowler, for instance, made an incision half-way between the anus and the point of the coccyx, and after separating the rectum from the latter and the sacrum inserted two fingers in the rectum, holding it up while its posterior wall was forced into the external wound and there held by heavy sutures of kangaroo tendon. By further incision he brought out the ends of these sutures on each side of the coccyx and tied them across the bone, thus by traction bringing the rectum up into position.

Colopexy has been practised as a more radical measure for the same purpose. As advised by Bryant the abdomen is opened by an incision parallel to Poupart’s ligament on the left side and one inch above it, and the prolapse is reduced by firmly pulling the rectum upward. It is then secured to the peritoneum about it, and is held by quilting sutures, which include the entire muscular coat of the bowel. Save in exceptionally favorable cases one or the other of these methods may be considered preferable to the complete amputation above described.

HEMORRHOIDS; PILES.

Hemorrhoids constitute perhaps the most common and, in some respects, uncomfortable or distressing disease of the rectum. The term implies a varicose condition of the lower veins, sometimes those of one set of hemorrhoidal veins being involved, at other times nearly all of them participating. They are spoken of as external or internal. In the former case it is the external hemorrhoidal veins alone which are involved, and usually only two or three of them, although occasionally one sees outside the anus, as within, a general involvement of the entire venous distribution. A pile, then, is essentially a venous angioma, or a single varicosity, and its peculiar features are due solely to its location.

Any vein thus involved is liable to the same dangers and accidents as veins in other parts of the body. Thus it may undergo dilatation, thrombosis, and suppuration, while the ordinary consequences of the latter condition may follow here, as elsewhere, with this difference alone, that when the middle and upper hemorrhoidal plexuses are involved the thromboseptic process, should it occur, follows the portal vein, and the first metastatic abscess that forms occurs within the liver. Thence it may spread to other parts of the body in classic form.

The hemorrhoidal veins, save those at the verge of the anus, are more or less entangled among the fibers of the levator ani and the sphincter. These muscles are thrown into a condition of more or less spasmodic contraction when the veins are so involved. In consequence more pressure is made upon the veins themselves, and the conditions of spasm and venous engorgement react upon each other in a vicious circle, each tending to make the other worse. Hence the great advantage of stretching the sphincter in any operation save that for a small external pile.

Hemorrhoidal angiomas may appear as single tumors or in multiple form surrounding the lower part of the rectum. The most common cause for their occurrence is chronic constipation. Occasionally the first exciting agent is some violent strain in defecation, or possibly the actual rupture of a small vessel, but such constant overloading of the rectum as obstructs its return circulation conduces to engorgement and the other conditions may easily follow. A small pile may be brought into existence in brief time, but a general hemorrhoidal condition is one of slow development. Chronic cases are always accompanied by further changes involving the surrounding connective tissue and the overlying mucosa, both of which become thickened and infiltrated, while ulcers form frequently upon the latter, and the occurrence of those linear ulcers which are ordinarily called fissures is very frequent. This gives an additionally distressing feature to these cases. As the condition goes on and the angiomas increase in size there is an increasing tendency to prolapse. This may be temporary or constant, i. e., it may occur with the straining effort at stool or it may result in a condition of permanent protrusion at the anus of the engorged mucosa; or, if the sphincter has finally become prolapsed a true prolapse of the rectum may result. A mucous surface thus constantly exposed to irritation will nearly always be more or less ulcerated and tender, while hemorrhages in either variety are common. It is not an infrequent event, then, for a patient to lose a number of ounces of blood with or just after stool, and sometimes the blood loss is even excessive. There is then added to the local condition a secondary feature of anemia and its attendant consequences which are sometimes extreme, and may even make operation somewhat hazardous. The lower inch and a half of the rectum is the portion particularly supplied with sensory nerves, and, under these circumstances, the irritated area becomes erethistic and painful and the patient’s suffering may be extreme. This is the so-called “pile-bearing area,” as it is within it that the hemorrhoidal condition is practically confined. Even a small individual pile connected with one of the little external veins may give rise to a disproportionate amount of discomfort.

There has been so much quack literature upon this general subject that ignorant patients are very likely to say that they have piles, no matter what may be the local condition. A statement to this effect should, first of all, provoke a physical examination with the finger, then with the speculum. The educated finger will easily detect the presence of the rugosities or tumors produced by internal piles, the external being always self-evident. The coexistence of ulceration will be indicated by an extreme degree of sphincteric spasm and of tenderness. It should be remembered that, along with hemorrhoids, there may coexist fissure, ulcer, painful spasm, prolapse, and, in long-existent cases, even cancer. The average patient with cancer of the rectum will go to his physician saying that he thinks he has piles.

Treatment.

—Treatment needs to be something more than merely local in aggravated cases, as it should also be more comprehensive. Patients who have thus long suffered have almost inevitably contracted the constipated habit, postponing defecation whenever possible because of pain and tenderness, and perhaps the hemorrhage accompanying it. The large bowel has, therefore, become weakened, and attention should be given to it as well as to the general digestive process.

Locally very mild degrees of purely temporary disturbance may be sometimes acceptably and temporarily treated by the use of suppositories containing some soothing and anodyne drug, as well as ergotin, the latter being valuable because of its constringent effect upon the bloodvessels. A five-grain gelatin-coated pill of ergotin makes a satisfactory suppository for the young, under these conditions.

A freshly formed, external hemorrhoid, which may attain a size no larger than that of a pea, but which will seem to the patient as large as a bird’s egg, is best treated by open division, turning out the blood or clot contained within the dilated vein, which will quickly obliterate, so that recovery will be complete within two or three days. This may be done under local anesthesia and with prompt relief. There have been methods in vogue, especially among the charlatans and some of the specialists, of treating external and the more localized internal conditions by injection of carbolic acid, either pure or reduced with a little glycerin. A few drops are thrown into the tumor with a hypodermic needle, the effect being to promptly coagulate the contained blood, the intent being to produce a final cure by absorption of the clot and obliteration of the veins. This, in fact, is the secret method long employed by the travelling charlatans and often connected with the name of Brinkerhof. It is uncertain in action, and the production of a clot under these conditions is by no means always free from danger, nor is the relief prompt. What is desired is to empty the vein and turn out the clot rather than to provoke its production. The method is rarely practised by judicious surgeons, who have too often seen serious sloughing and even general septic disturbance follow it.

For the radical relief of distinctly hemorrhoidal conditions there is no satisfactory method save the operative. So many measures have been devised in time past that it is necessary here to be selective and only mention one or two. On general principles every pile is a venous tumor, and there is no reason why it should not be treated like any other tumor, i. e., by enucleation or excision. The same is true of the area which contains a number of such tumors, i. e., the so-called pile-bearing area. Hence, surgeons of the largest experience have practically discarded the more bungling methods and have applied to these conditions the same radical measures which they recommend elsewhere.

One important feature which should always be practised is thorough dilatation of the sphincter, not only for reasons above described, but because of the facility with which the surgeon then exposes the diseased tissues. Any distinct tumor or series of them may, for instance, be seized, isolated, and dissected out, either by an elliptical incision of the mucosa or by a more blunt dissection with scissors. The base, or pedicle, if sufficiently large to justify it, may be ligated before the incision is completed, after which catgut sutures may be used to close the opening in the mucosa. When the tumor is small the suture may be made to include the bleeding points so that even a ligature is not required. A more radical method of extending this same principle to the entire pile-bearing area, especially when prolapsed, or to so much of it as is affected, is the so-called Whitehead’s operation of excision, which practically consists in trimming off a ring of exposed mucosa, with its clusters of enlarged and more or less pendulous veins. This ring extends from the mucocutaneous border, at the verge of the anus, to a point perhaps 1¹⁄₂ inches above, the intent being to separate the mucosa and the tumors from the fibers of the sphincter, which can be practically effected in such a way that sphincter control is not lost. Hemorrhage will be free for a few moments, but is always within control. Larger vessels which spurt may be twisted or tied, while oozing surfaces are included within the row of catgut sutures, which is later placed in such a way as to unite the divided mucous tube with the skin border at the anus. The operation is, in effect, an annular excision of the lining of the rectum, and as such proves satisfactory. There is about it this temporary disadvantage that the pile-bearing area thus removed is also the sensitive area, and that for a few weeks, at least until nerve communications have been reëstablished, there is a lack of peculiar or normal sensibility about the parts which is annoying, and may perhaps lead to some incontinence, but this soon passes away. The measure is the most satisfactory of all for well-marked cases of hemorrhoids associated with more or less ulceration and prolapse.

An occasional dilatation, scattered here and there around the lower end of the rectum, perhaps with a mild degree of ulceration, is usually very satisfactorily treated by a method which it must be confessed would be rarely used on the exterior of the body, and yet which proves quite serviceable here, namely, the actual cautery. The consequences of its application are obliteration of the vein, cicatricial contraction of the overstretched tissues and eventual relief.

Other methods of operation include the use of the clamp and cautery for removal of considerable masses, a method ordinarily less satisfactory than excision, and the use of the ligature, with or without incision of the mucosa at the base of the tumor, it being thus cauterized and expected to separate by sloughing, an uncertain procedure. None of these methods, nor others not worth mentioning, compare with the newer methods of excision.

Much has been recently written concerning the advantage of local anesthesia in doing these operations. This seems to have been advocated largely for effect, although external tumors can be treated by cocaine applications or by the ordinary injections of cocaine or one of its substitutes. It is claimed that the infiltration of the surrounding tissues with normal salt solution affords an effective local anesthetic. Mere local anesthesia is not sufficient for thorough work upon parts not easily visible, and the actual stretching of the sphincter is half the battle in dealing with these conditions. This cannot be thoroughly accomplished without general anesthesia. Consequently for any well-marked hemorrhoidal condition chloroform offers decidedly the preferable method, not alone from considerations of comfort, but from the standpoint of permitting more thorough and effective work to be done.

After these operations it is advisable to place within the grasp of the anus a stiff rubber tube wrapped with gauze. It permits the escape of flatus without distress to the patient, and it effects a better coaptation of surfaces recently united by suture than would otherwise be secured. Such a tube may be left in situ for from six to thirty-six hours.

TUMORS OF THE RECTUM.

The rectum is the frequent site, more especially in children, of polypoid degenerations similar to those seen in the nose. In consequence there are formed the so-called rectal polypi, which, in origin, consistence, and course correspond to the common nasal polypi. Such a pedunculated tumor may attain considerable size, especially when solitary, while, on the other hand, the mucosa may be studded with small pedunculated growths, giving the appearance represented in Fig. 593.

Pathologically these polypi are originally of myxomatous or adenomatous type. They may bleed easily and may be passed with stool. In their multiple and smaller expressions they give rise rather to rectal uneasiness and tenesmus than to more distinct symptoms. On the other hand an isolated tumor, so pedunculated as to become gradually stretched out, may attain considerable size and give rise to all the sensations of a foreign body in the rectum, with constant tenesmus and desire to expel it, while it may even present at the anus or bleed freely.

Only exceptionally will these tumors be recognized previous to examination, which, however, should easily disclose their characteristics. Isolated polypi should be removed, either by being twisted off or by excision and ligature of their bases. General polypoid degeneration may be treated with the curette or with the actual cautery. In all these instances surgical intervention in some form will be required.

Other benign tumors in the rectum are mainly of the adenomatous type. Owing to their location it is rare that they are seen early by one competent to judge of them. In consequence the surgeon sees them usually as more or less ulcerated, sometimes extensive growths, perhaps bleeding freely, and much changed by maceration and by compression from their original condition.

In such cases it becomes a question of importance to distinguish between the benign and the cancerous growths. This is not always easily done, especially when they are high up and ulcerated. The matter is usually decided by the presence or absence of actual infiltration around the base of the growth, and perhaps the involvement of lymph nodes. A movable tumor with an infiltrated base is usually clinically benign, nevertheless it should be radically removed. It is in many of these instances that one may see expressions of transformation of adenoma into carcinoma.

Cancer of the Rectum.

—This will be considered here rather from its clinical side; hence what is said refers alike to sarcoma and carcinoma, the latter being far more common. Carcinoma of the rectum may assume the type either of epithelioma, as when it begins low and spreads upward, or of adenocarcinoma, when it arises from that portion of the tube not lined with squamous epithelium.

It usually begins insidiously, and for a considerable length of time furnishes scarcely any recognizable symptom. The first indications noticed by the patient are usually more or less frequency of stool, with tenesmus, and the passage of mucus, perhaps stained with blood, rather than of fecal matter. By the time those conditions are noticed there will usually be more or less mechanical difficulty of defecation, due to the presence of the tumor and obstruction of the rectal tube. Pain may be a long-deferred feature, and local soreness may be absent until late in the case or until its terminal stage, when the growth is above the peculiarly sensitive part of the rectum, i. e., when it does not approach to within 1¹⁄₂ inches of the sphincter. As time goes on there is more and more suffering in the rectum, with backache, referred pain, while the tenesmus and other local conditions cause increasing distress. It often happens that it is not until this period is reached that the patient consults a physician, and then he usually goes with the statement that he is suffering from piles.

So frequently is this the case, and so prone are many practitioners to accept such a statement, that the proper examination which should permit the recognition of the condition is perhaps not made until the patient is really in a pitiable condition. I do not recall ever having seen a case of cancer of the rectum which had not been regarded, by some physician as piles, and in most cases locally treated by him, usually without any adequate local examination, and usually also until the time had passed when a radical operation could be practised with any degree of hope. The first examination at least will be digital, and if the malignant growth be within reach of the finger it should be possible to appreciate it, to estimate its size, degree of attachment, and the amount of infiltration, as well as the extent to which it is breaking down. A soft, rapidly growing cancer will give a fungous sensation to the finger, while the more dense, scirrhous forms produce hard masses, growing in irregular shapes, sometimes involving one side of the bowel, sometimes appearing in annular form, and tending sooner or later to produce malignant destruction. The only difficulty would be in cases seen exceptionally early or in those beyond reach. The circumstances above detailed should lead to a careful proctoscopic examination with suitable instruments, perhaps in the knee-chest position, when the growth is not easily appreciated from below. Any complaint of tenesmus, with discharge of blood and mucus, with more or less pain and tenderness, local or referred, demands an examination sufficiently careful to reveal the nature and extent of the lesion and indicate the treatment. If such an examination call for an anesthetic, it should be administered. Practically every rectal cancer is a malignant ulcer by the time it is recognized, ulceration being favored by warmth and moisture.

Treatment.

—There are few malignant lesions anywhere about the body which require more good judgment in treatment than cases of cancer of the rectum. So much depends upon their location, their extent, the degree of infiltration, the age and general condition of the patient, that it is almost impossible to lay down succinct rules. The question of treatment hinges, first, upon the location and extent of the lesion; is it operable or is it not? When the lymph nodes of the pelvis or the groin are noticeably involved it is practically too late, under any circumstances, to hold out prospect of radical cure. When the disease has extended far above reach of the finger it is again late to expect much even from radical measures. When the prostate, the floor of the bladder, the vagina, or any of the pelvic viscera are involved it is again too late to justify them. There are wide differences of opinion between surgeons as to the propriety of extensive operations in serious cases. Mild cases are certainly much benefited and even actually cured by early and thorough removal, but this occurs too infrequently, because such cases are rarely seen sufficiently early.

The class of cases universally acknowledged to be inoperable, so far as radical measures are concerned, are nevertheless much benefited and their lives prolonged by a colostomy, the effect being to provide an easy and manageable outlet for fecal discharge, and to avoid the irritation and attendant difficulties associated with an obstructed and malignantly ulcerated rectal outlet. The surgeon has to select between some method of excision and colostomy. My own opinion is growing in favor of the latter, save when the prospect of complete excision is good. The opening is more manageable, the progress of the disease seems much checked, patients have better fecal control and live in far greater comfort, while their lives are placed in less jeopardy, and, in general, are actually prolonged. Thus a colostomy performed in a well-marked case of inoperable cancer of the rectum may permit of prolongation of life for two or three years, something not often attained by any other method of treatment.

Of the various radical operations some are made from below, i. e., by the perineal route, some by the so-called sacral route, and some from above. Of the latter it may be said that occasionally an annular cancer of the rectum is seen so favorably located that by opening the abdomen with the patient in the Trendelenburg position it is possible to make a complete excision of the growth, to remove enlarged lymph nodes, and to make an end-to-end reunion with success. In a case in my own practice nearly six years have elapsed since this operation was done, and the patient, a young woman, is still absolutely free from the disease.

Through the perineum the lower portion of the rectum may be attacked either by splitting the sphincter and dividing it posteriorly, completely dissecting out the gut from its surroundings, removing all infiltrated tissue, and then, by dividing the bowel above the growth, amputating the lower part. It may be possible to bring down the upper end and attach it to the mucocutaneous border of the anus, reuniting the divided sphincter, and aiming for a restoration to something like the original condition, which under quite favorable conditions is attainable. At other times it will be impracticable to thus attach the lower end of the tube because it has been too much shortened, and in these cases it should be brought out through a posterior incision just below the tip of the coccyx, or higher up if the bone has been removed. Here the rectal outlet is placed posteriorly, but is devoid of a sphincter. Something like sphincteric action can be provided by giving it a third or half of a revolution on its axis before fastening it to the external wound. After this expedient more or less control of solid fecal matter is afforded.

The more complete and radical operations, associated with the names of Kraske and other operators, include removal of the coccyx, and of the lower portion of the sacrum, which are usually completely excised, although certain “trap-door” operations have been devised. If the sacrum be not cut away above the third sacral foramen there is not much damage done to the nerves, while sufficient room is afforded for any removal that is justifiable. Some operators open the peritoneum, others attempt to avoid it. If the growth be attached to that membrane it becomes necessary. If peritoneal invasion can be avoided it is desirable. It is possible to completely expose the contents of the pelvis through such an opening, while from this direction, the gut being withdrawn after the peritoneum is divided, the pouch of Douglas may be opened and further removal of diseased tissue be effected. In all these operations the endeavor should be to disturb the mesosigmoid and the mesorectum as little as possible, in order to not interfere with blood supply, for reasons already mentioned when discussing the mesentery.

In all these operations contamination of the wound should be avoided, especially of the peritoneum, by clamping or ligating the bowel, or by amply packing and by every possible additional precaution. Bowel should be divided between two clamps and the divided edges at once thoroughly cleansed with compresses and with hydrogen peroxide.

One may read in the works on operative surgery descriptions of most extensive and elaborate operations of this general character, and of extensive and even daring feats of removal, where portions of the bladder, of the tubes, of the ovaries, even the uterus, have been removed. It has seemed to me that the surgeon should avoid operative gymnastics, especially in this region, so far as possible, and confine himself to measures which if successful would improve conditions rather than complicate them. My own judgment then is that in any case where so formidable an operation would be attempted by some, the best interests of the patient will be served rather by simple colostomy.

Early operations upon cancer of the rectum afford comforting prospects. It is not so much to the discredit of surgery as to the discredit of the patient’s judgment, and of the carelessness of the practitioners who first see these cases, that cancer of the rectum has become such a bête noir and is justly regarded as so serious and unpromising a measure.[60]

Colostomy.

—Colostomy for relief of rectal cancer is not a radical operation, but in many cases is far more humane and satisfactory than are those alluded to above. The intent is to make an opening in the left side of the groin at a point where it is easily made. There are two methods of performing colostomy here. One is to make an opening through the abdominal wall, attach to it the presenting surface of the sigmoid or colon, and either open it at once or some hours later, when adhesions have cemented the desired union. Such an opening may be made for emergency purposes under local anesthesia, but when the colon is movable, and when the disease has not yet involved the area thus exposed, or any portion above it, a more desirable method is a deliberate one. An opening is made such as is usually made on the right side when operating upon the appendix. The bowel thus being accessible is divided between two clamps, while the end of the lower segment is inverted and closed with chromic or silk sutures, after which it is dropped back. This leaves the upper portion with its open end corresponding to the abdominal opening, into which it is fastened by a series of sutures, being attached to the peritoneum and to the deep musculature rather than to the skin, for if it be brought out too freely and attached externally there is greater tendency to prolapse and subsequent discomfort. Into the opening thus afforded a large-sized rubber or bent glass tube is inserted for a few inches, around which gauze is packed, and every effort is made to conduct fecal matter to the exterior, as well to protect, at least for a few hours, the wound itself from fecal contamination. Improvements in this technique have been suggested, such as tying into the bowel a curved glass tube, thus conducting its contents into a rubber bag or receptacle placed outside the dressing. Another method which has been suggested by Stewart is to connect the interior of the colon by a Murphy button with a rubber bag or rubber dam upon the outside of the abdomen, by which protection for this purpose can be afforded.

This operation makes a complete and final division of the colon, and permanently excludes the rectum with its cancerous involvement. It is not, therefore, in this respect, a radical measure. The result, however, is that if the rectum be washed from below each day it is kept far cleaner and freer from contact with irritative foreign material than it otherwise would be. Furthermore, being disused it tends to undergo to some degree a species of physiological atrophy, and, in consequence, the cancer grows more slowly, if there do not occur an apparent temporary cessation of malignant activity.

By suitable management of the artificial anus, including the deliberate emptying of the bowel every morning and the use of protective pads for receptacles, it can be made far less disagreeable than patients ordinarily fear (Figs. 595 and 596).

The colostomy opening in the abdominal wall should be made as small as practicable lest there occur not only more or less ventral hernia through the weakened outlet, but even, as I have seen in one case, a most extensive prolapse of the colon, in which two or three years after performance of the operation the colon could be made to prolapse to an extent of twelve or fifteen inches.