T5.e^ with reduction. Wherever the stimulus was applied the effect was. the same, namely reduction of the intussusception. It was not possible to make the intussusception progress by means of stimulation of the bowel wall ; the effect was always the opposite,, namely, rapid reduction. Mechanical stimuli, by touching or nipping the bowel, were INTUSSUSCEPTION 117 tried in place of the electrical stimulus, but the effect was the same. In some cases a slight contraction occurred at A, but within a few seconds, a second and stronger ring of contraction occurred at B, and passed backwards until the intussusception was reduced. I then tried making an artificial retrograde intussusception in the colon ; this soon reduced itself if left alone, and, if stimu- lated, reduced itself more quickly. I found, in fact, that in a normal bowel wall an intussusception tended to reduce itself and not to be progressive, even when violent contraction occurred. These experiments go to prove that an intussusception cannot occur in a normal bowel, but that some other factor must be present. My experiments do not agree with those of Nothnagel, who said that he obtained artificial intussusceptions by tetanizing rabbits' intestine with electrodes. Experiments on the same lines carried out by myself have absolutely failed to produce a similar result. The real explanation of intussusception seems to be clearly shown where a polypus is the starting-point of the invagination. The polypus acts as a foreign body and stimulates the bowel to pass it on ; being attached to the bowel wall by a pedicle, it pulls this in after it, and, as the polypus is carried further and further down the bowel, more bowel wall is drawn in, and intussusception is produced. It seems probable that this is the real explanation in all cases. True, a poh'pus is not always present, but some other lesion is, which acts in the same wa3'. Cases in which a polypus forms the apex of an intussusception are easily explained by this view, but it is not so easy to account for the common ileo-Ccecal form met with in infants. The late Mr. Barnard attempted this b}' assuming that pro- lapse of the ileum occurs through the ileo-caecal valve, in the same way that prolapse of the rectum takes place through the anal sphincter. Prolapse of the rectum is common in children, and he beheved that prolapse through the ileo-csecal valve is also often present in children under similar conditions. He argued that the prolapse acts like a foreign body in originating the intussusception. There are, however, several facts opposed to this view. Prolapse of the rectum usually occurs in children who have ii8 INTUSSUSCEPTION been neglected, who are thin, badly nourished, or recovering from illness, such as measles and whooping-cough, or it follows infantile diarrhoea. fin St SEASONAL a) f- >> c a rt 3 -c s: "3 INFLUEffCE. ^ • /+J • -• 3 3 U O ^ ■< U5 O o 55 RO h f A'^ 1 V / 40 / ^ ^. / f'^i •^ 7 s. \, 50 \ 7 25 \ V •^ ^ ?r» V <** !«; 10 5 57 35 58 45 44 41 57 33 18 25 29 5' Tot.al 453. Fig. 40. — Chart showing seasonal' incidence of intussusceptions in 453 cases not older than is months. (FitziviUiams.) MOkTHS YEARS 1 2 3 ,4 5 6 7 8 9 101 II2I3MZ 3 4 5 6 7 8 9101 I 12 85 . 80 75 70 65 60 55 50 45 40 35 SO 25 20 16 10' 5 h -^ I 4Z i 1 I t L T :i i^ i ^ t i^ J> A . t :^ h^\ X '"""" \' "-^ 1 \/ V .-^ ifllt ^ ^^^ ^- Fig. 41. — Chart showing age incidence in months and years in 64S cases under 12 years of age. ( Fitz-duilliams. ) Almost without exception, however, the infants who get intussusception are well nourished, fat, sturdy children, who, INTUSSUSCEPTION 119 until the illness began, were in perfect health. Also, if intussus- ception resulted from prolapse, one would expect it to be common at those times of the year when diarrhoea is common, as is rectal prolapse in children. This is, however, far from being the case. Mr. Fitzwilliams, in a recent paper,* analysed 453 cases accord- ing to the time of the year at which they occurred. The chart {Fig. 40) shows that the condition is commonest during March and December, and least common in August and September, the months during which diarrhoea is commonest. FitzwiUiams has pointed out that March and December (owing to Easter and Christmas) are the times at which children are most hkely to overeat themselves, or to eat indigestible foods. While the prolapse theory does not seem tenable, the following explanation appears to be possible and to fit all the facts. If a Fig. 42. — Diagram showing how a lump of indigestible food may produce an intussusception by becoming impacted in the ileo-caecal valve. child is given some indigestible food, part of this may form an indigestible bolus too large to pass through the ileo-caecal valve. When it reaches this valve it either becomes impacted, or remains above and blocks it. Violent peristalsis will then occur in the ileum above, and the mass being unable to move, the whole ileo-caecal valve is forced into the caecum, the invagination being aided by antiperistalsis which is probably occurring in the ascending colon and caecum as the result of food which has just previously passed the valve. Lumps of undigested matter are commonly found in the apex of an intussusception, and when they are not, it is reasonable to suppose that they have eventually become digested or have been squeezed through * Lancet, February 29 and March 7, 1908, 120 INTUSSUSCEPTION the valve. This explanation fits in with the known incidence of the condition as shown by Fitzwilliams, and also with the fact that the ileo-caecal variety of intussusception is so much the commonest. Fitzwilliams suggests that the most probable cause of this condition in infants is the giving of unsuitable food before the child is able to digest it. Such food as crusts and biscuit are often given with the false idea of assisting the child to cut his teeth. There is every reason to believe this to be the correct explanation. Cancer is not an uncommon cause of intussusception in the colon. The form of such a cancer is most commonly that in which the growth protrudes into the bowel lumen and forms a polypoid mass. The growth in such cases forms the apex of the invagination, and cases are on record in which a growth of the sigmoid or descending colon has projected at the anus. The late Mr. Barnard describes a form of intussusception which results from a relaxed or paralyzed condition of the colon, the healthy bowel invaginating into the relaxed portion. This condition usually leads to a chronic form of intussusception with chronic constipation rather than acute obstruction. Indeed, it is not improbable that some of the obscure and obstinate cases of chronic constipation result from a recurring intussus- ception of this nature. The same observer also described a very rare form of intussus- ception of the colon which originated in gangrene of the trans- verse colon. The whole of the gangrenous portion of the colon was ultimately passed per anum, and the patient recovered, with a stenosis which required subsequent operation. A case is reported by Mr. Ray,* in which an intussuscep- tion of the sigmoid flexure resulted from a subserous polypoid lipoma. The patient was a woman aged 30. The apex of the intussusception protruded from the anus. The patient was operated upon and the polypus successfully removed. Pathology. In acute intussusception, strangulation soon occurs and the invagination becomes irreducible. The blood-supply of the layers forming the intussusception is interferred with, * Lancet, March 4, 1905 INTUSSUSCEPTION 121 and, as a result, there is oedema and swelling, which still further increases the strangulation of the intussusceptum or central portion. The sheath itself seldom suffers much damage, as its blood-supply is not interfered with ; the chief mischief occurs in the middle layer. The first serious change is that the entering and returning layers become firmly fixed together. This occurs first near the apex of the invagination, — that is to say, at the part which is the last to be reduced, the result being to make the intussus- ception irreducible. First, only the part near the apex is irreducible, but in time the whole may become so. Later the two inner layers become gangrenous. This usually occurs first at the neck, where the collar formed by the turning over of the ensheathing layer constricts the entering layer. The time before gangrene may appear varies in different cases. It has been seen in thirty hours, but more usually it takes three to four days, and sometimes much longer. Death as a rule occurs from exhaustion or peritonitis. The bowel above the intussusception does not usually undergo any marked alteration except in chronic cases. In chronic cases of intussusception, there is obstruction but no strangulation. Even the obstruction is not complete, or at least is intermittent. If the condition exists for a long time, the usual secondary changes will be found in the bowel above, namely, dilatation and hypertrophy. Ulceration may also occur both in the intussusception and in the bowel above it. Spontaneous Elimination of the Intussusception. — This occa- sionally occurs owing to gangrene at the neck allowing the invaginated portion of the bowel to become free, thus restoring the bowel lumen, and allowing the separated invagination to be passed per anum. As a result of the inflammation around the gangrenous area the entering layer and the sheath become fixed together, thus restoring the continuity of the bowel after the intussusception has been cast off. Very considerable lengths of bowel may in this way be ehminated, and cases are recorded in which as much as 3 feet or more of bowel have become separated and passed in the stools. Spontaneous cure of an intussusception may thus occur, but it does not do so in more than about i per cent of cases, and recovery is doubtful even after it has occurred. 122 INTUSSUSCEPTION Symptoms. Intussusception may occur at any age, but is most common in early infancy. The late Mr. Barnard, from a study of 187 cases taken from the records of the London Hospital, found that 72 per cent occurred in children less than a year old, and 88 per cent in children under 10 years of age. Mr. Fitz- williams, from an analysis of 648 cases occurring in children under 12 years of age, found that 72 per cent were in those under 12 months old ; 20 per cent between the ages of I and 6 years ; and 6 per cent between the ages of 7 and 12 years. He also found that the greatest number of cases occurred in infants between the 4th and 7th months of life. The condition is much commoner in males than in females, the proportion being about 2 to i. Fitzwilliams' statistics give 68 per cent males and 32 per cent females, figures which agree very closely with those of other observers. Cases of intussusception divide themselves into two types : (i) Those in which the symptoms are acute ; and (2) Chronic cases, in which symptoms persist for a considerable time without causing death. Cases of the latter type are usually seen in adults, and in the common form of intussusception which occurs in infants the symptoms are almost without exception acute. The symptoms in the acute cases are well marked and dis- tinctive, and the following is typical of the variety most usually met with : — The patient, a well-nourished and previously healthy infant, is suddenly seized with violent colic ; it begins to scream, and shows all the signs of acute abdominal pain. It lies on its back with its knees drawn up, screaming with pain, and refuses to be pacified. The child usually vomits once or twice immediately after the onset of the pain. Though vomiting is a common occurrence at first, it usually does not continue, and is not a marked feature in most cases. There is much tenesmus and straining, and the child passes stools consisting principally, and sometimes entirely, of blood and mucus. The stools look like apple jelly, and are the most characteristic feature of the disease, and the one upon which the diagnosis principally depends. These apple-jelly stools are frequent, and their passage is accom- panied by much straining. An examination of the abdomen reveals a distinct sausage-shaped tumour in about two-thirds of INTUSSUSCEPTION 123 the cases. If the diagnosis is in doubt and nothing can be felt, an anaesthetic should be administered, when a tumour will usually be easily made out : it is sausage-shaped, and generally situated either in the right iliac fossa or across the abdomen at about the level of the umbilicus. In some cases the apex of the intus- susception can be felt on making a rectal examination. The condition once established rapidly gets worse, and the child soon passes into a dangerous state, with collapse, coldness of the extremities, rapid pulse, and distended abdomen. If un- reheved, a fatal result generally follows in from two to eight days. The typical s3"mptoms are acute abdominal pain, coming on suddenly and accompanied by a palpable tumour in the abdomen, and blood and mucus in the stools. Such symptoms in a child are characteristic of intussusception, but although the clinical picture is as a rule well marked, considerable variations may occur. Thus the condition may supervene upon an attack of diarrhoea or indigestion, or the child may be seen before any stool containing blood has been passed. If the child comes under observation soon after the onset of the illness, it may be difficult to make a correct diagnosis, though there will seldom be any doubt as to a serious abdominal lesion being present, and if the patient is watched for a few hours the diagnosis will be cleared up. When the child is first seen after the condition has existed for some time, there will be marked collapse, with paleness and coldness of the extremities, the face will be drawn, the abdomen distended, and all the signs of impending death will be observed. The diagnosis is generally not difficult. It depends principally upon being able to feel a tumour in the abdomen. This is a positive and certain sign. If there is doubt, and no tumour can be felt, an anaesthetic should be administered and the abdomen carefully examined bimanually with one finger in the rectum. In the case of intussusception in adults, and chronic intussus- ception, the symptoms vary so greatly in different patients that it is impossible to give any characteristic symptoms or to lay down rules by which the condition may be diagnosed. The symptoms are those of intestinal obstruction coming on in- sidiously or of an intermittent character, and it is seldom that an exact diagnosis of the lesion can be made bej'ond the con- clusion that some lesion is present, causing obstruction. 124 INTUSSUSCEPTION Treatment. Non-operative Treatment. — The proper treatment is im- mediate operation. Although reduction can sometimes be effected by the injection of fluid into the bowel per anum, this method is very uncertain. It only succeeds in a small percent- age of cases, and reduction is often not complete. Failing the possibility of immediate operation, it should be attempted, but if an operation can be performed it is useless to delay operating while injection is being tried, for if the injection method fails, as it probably will, the patient will be in a less favourable condition for operation afterwards. The Injection Method of Reduction. — The child should be anaesthetized, and placed in a position with the buttocks well raised on a cushion. A rectal tube is then introduced into the anus, and to this a glass funnel and tube are attached. Warm water is the best fluid, and this should be run in slowly with a drop of not more than about 3 feet. Gentle manipulation of the tumour through the abdominal wall will assist in reduction. The injection may need to be repeated before reduction is complete. If this is successfully accomplished, the child must be carefully watched for the next day or two to see that the intussusception does not recur, as it is apt to do. Operative Treatment. — The abdomen should be opened near the middle line as a rule, but this will depend to some extent upon the variety of intussusception present, its position, and size. If the intussusception is not too large it should be delivered through the abdominal wound. If this is impossible owing to its size, it should be partly reduced in situ, and the remainder then delivered before reducing the last portion. The greatest difficulty is generally experienced in reducing the last two or three inches, and if possible it is advisable to be able to do this outside the abdomen, when the exact condition of affairs can be seen and the condition of the bowel better observed. The best method of reduction is b}^ catching hold of the colon opposite the apex of the intussusception and gradually squeezing the latter back. It is better if possible to avoid pulling upon the entering layer, and to reduce the condition entirely by squeezing back the apex of the invagination. In reducing the last two or three inches it is necessar}^ to use the greatest care in order to avoid tearing the gut, which is often ver}'- friable at this point. INTUSSUSCEPTION 125 If the condition can be completely reduced, and the gut is not too much injured to recover, the bowel should be returned into the abdomen and the latter closed as quickly as possible. Intussusception usually occurs in very young children, and success depends very largely upon operating rapidly, and getting the small patient back to bed with as little delay as possible. For the first few hours the foot of the bed should be raised on blocks. Care should also be taken to see that the child's respiration is not embarrassed by heav}' bedclothes resting upon the chest, since the breathing is already to some extent interfered with by the abdominal binder. Nourishment should also be adminis- tered as soon as possible, either by the mouth or rectum. When reduction is not possible, or the bowel is too much damaged for there to be any reasonable hope of its recovery, it becomes necessary to consider what is to be done. The ideal method is to excise that portion of bowel containing the intussusception and to anastamose the ends. The difficulty is that in most cases the patient is not in a condition to stand so severe and prolonged an operation as this necessitates. The only other alternative is to perform colotomy, either by excising the intussusception and tying a Paul's tube into the two ends of the bowel, or by bringing out that part of the intussusception which cannot be reduced, and after stitching- it to the skin, opening it. Much will depend upon the circumstances of the case and the skill of the operator. Except in adults and older children, most cases of irreducible intussusception die, whatever is done. There have, however, been several successful operations recorded in which resection and end-to-end anastomosis have been followed by recovery. The following case recorded by F. W. Collinson* is a good instance of recovery after resection. Case. — The patient was 3 months old. Symptoms of intussus- ception had been present for seventeen hours ; chloroform was ad- ministered and the abdomen opened in the middle hne. The intussusception was easily reduced, all but the last 4 inches, which were irreducible and dusky in colour. The bowel was clamped above and below, and the intussusception resected. The parts removed consisted of 2 J inches of the ileum, the caecum, and part of the ascending colon, some 7 inches in all. The ends of the divided * Lancet, October 19, 1907. 126 INTUSSUSCEPTION bowel were brought together with a Robson's bobbin and the abdomen closed. Two and a half hours after the operation the child was put to its mother's breast, and after this, feeding was continued every three hours. The bowels acted ten hours after operation. The bobbin was passed on the fifth day. The child made an uneventful recovery. In chronic intussusception, operation is the only treatment. The greater part of the invagination is as a rule easily reduced, but there is often difficulty in reducing the last portion, and resection in some form has to be done. Resection with end-to- end anastomosis appears to give the best results and; owing to the better condition of the patient previous to operation, is not attended by so high a mortality as in the acute cases. The lower mortality from resection in chronic cases is also to some extent accounted for by the fact that the patients are generally older. The following table shows the results of resection and end-to- end anastomosis by suture in 7 chronic cases of intussusception. Czerny F age 36 Died. M ,,52 Recovered. M ,,13 Recovered. Boif&n M ,,24 Recovered. Braun F ,,23 Recovered. Miiller — — Died. N.B. — 150 cms. resected. Rosenthal! F ,, 35 Recovered. N.B. — 60 cms. resected. Prognosis. This is good when operation is performed early and the intussusception can be reduced. It is bad in acute cases when more than twenty-four hours have elapsed since the onset of the condition, and when reduction is impossible. REFERENCES. H. L. Barnard. — "Intestinal Obstruction," Allbiitt and Rolleston's System of Medicine, 2nd ed. vol. iii. C. D. L. FiTzwiLLiAMS. — "The Pathology and Etiologv of Intussuscep- tion, from the Study of 1,000 Cases," Lancet, Feb. 29 and Mar. 7, 1908. 127 Chapter XI. CHRONIC MUCOUS OR MEMBRANOUS COLITIS. Chronic mucous or membranous colitis is a name given to a condition of which the chief symptoms are an excess of mucus in the stools, accompanied by abdominal pain, usually of a paroxysmal type. The condition is a badly defined one, and vaiious names have been given it by different writers. To mention only a few : it has been described as colica mucosa, membranous or mucous diarrhoea, entero-cohtis, mucous croup, enteritis membranacea, and glutinous diarrhoea. All these, and several others, have been used to designate what is without doubt the same complaint. The distinguishing feature of the condition is the passage in the stools of mucus in abnormal quantities. Patients in whose stools this mucus is present, usually suffer more or less con- tinuoush' from abdominal discomfort, from constipation which is often extreme, and occasional^ in the more severe cases,' from violent colicky abdominal pain. This gives the essential features of a condition which has been described as a disease under the before-mentioned names, and about which much has been written. In Germany especially, long theses have been written upon it, and numerous specula- tions have been made as to its causation. Prof. Nothnagel, who was one of the first to describe it, believes it to be a secretory neurosis without any lesion in the colon, due to some condition of the central nervous system. He claims that the neurasthenia which often accompanies the disease is the cause of it. In this view Nothnagel has many followers, among whom may be mentioned Westphalen, King, Harrison, Osier, Weigert, and others. They get over the obvious difficulty that it is some- times found associated with definite lesions of the colon, by putting these in a separate class and calUng them secondary colitis. The condition has been compared to croup and asthma. 128 CHRONIC MUCOUS OR and the most elaborate theories have been propounded to account for the various symptoms on the neurotic theory. On the other hand, Von Noorden, Boas, Tuttle, the author, and other writers maintain that the condition is a real colitis, with definite lesions in the colon. The whole subject has become much confused, and the various hypotheses are so conflicting that it is difficult to unravel the truth. The name itself is confusing, as colitis, if it means anything, implies inflammation, the existence of which many writers deny. The condition has been variously classified and divided on every kind of basis ; thus we find one writer classifying the condition according to the appearance and form of the mucus present in the stools, while another divides it in reference to its supposed causes. Symptoms. Chronic mucous colitis is most frequently met with in women, between the ages of twenty-five and forty. It is, however, not uncommon in men, and one of the reasons why it is more frequently seen in women is that men are less prone to seek medical advice on account of vague symptoms, and consequently the less severe cases are often not diagnosed. Though it is most common between the ages of twenty-five and forty, it is by no means confined to this period of life ; several cases have been recorded in children ten years of age, and I have seen it in a patient of eighty-two. The most characteristic symptom of the condition is the passage of mucus in the stools, and it is this which provides its name and often first draws attention to it. The mucus may be present in the lorm of shreds, or may form large casts of the bowel. I have seen such casts over a foot long, and the patient on seeing the casts under such circumstances is often much alarmed, not infrequently imagining that she has passed some curious and abnormally large worm. The amount of mucus present in the stools is often considerable, and they sometimes consist of little else. In a typical case the symptoms occur periodically. Previous to an attack there is usually a period of constipation, the bowels for some weeks becoming more and more difficult to relieve. This is followed by a sudden paroxysm of acute abdominal pain. The patient feels ill, and has severe colic. In severe MEMBRANOUS COLITIS 129 cases there maybe vomiting, and a feeling of sickness is common. The pain continues with more or less severity for from twenty- four hours to a week. I have seen instances in which it was so severe as to necessitate the use of morphia, and to prevent sleep, and where the sj'mptoms have been mistaken for intestinal obstruction or appendicitis. The temperature, however, is usually normal. The crisis terminates with an action of the bowels, most usually with diarrhoea. Each act of defaecation is, as a rule, accompanied by pain and tenesmus, so that the patient has been known to faint at stool. The first stools passed after an attack consist almost entirely of mucus, often in the form of casts or membranes. When the bowels act, the abdominal pain passes off and the patient is better for a time. In some patients the attacks recur as often as once a month, in others only twice or thrice a year. Some enjoy fair health in the intervals, while others are more or less chronic invalids. The paroxysms are most common in those patients who pass casts and large membranes, and it seems probable that the severe pain is due to the bowel becoming blocked by masses which have become detached from the mucous membrane, and to the violent peristaltic efforts at expulsion ; it ceases as soon as the membrane has been got rid of. Many patients with chronic mucous colitis, however, never have these attacks. They suffer from chronic abdominal discomfort rather than actual pain, and mucus is more or less constantly present in their stools. The tongue is furred, there is a feeling of discomfort after food, and great mental and general depression. Flatulence and distention are common symptoms, and there is almost invariably severe constipation or a history of previous constipation. The patient has generally a very poor appetite, often only being able to eat a few special articles of diet. One of my patients had practically lived on milk for eighteen months. As already mentioned, constipation is the rule. It is often severe, so that the patient is only able to relieve the bowels by large doses of aperients, and then at uncertain and infrequent intervals. In quite a number of cases, however, there is diar- rhoea, though even in these there is an antecedent history of constipation. I have seen patients who had as many as sixteen and twentv stools in the twenty-four hours ; but the diarrhoea is 9 130 CHRONIC MUCOUS OR often to a large extent spurious ; that is to say, there is very httle faecal material, but the stools consist of a small quantit}^ often not more than an ounce, of mucus and water. Therefore, although the bowels may be acting very frequently, the actual amount of faecal material passed is often much below the normal. This diarrhoea is sometimes accompanied by considerable pain and tenesmus. There is often considerable loss of flesh, and the patient is generally much below the normal weight. It is not uncommon for a patient to lose a couple of stone in the course of a few months. This loss of weight is perhaps best seen where there is diarrhoea. Mental Condition. — This varies considerabty. In a large percentage of cases the patient is markedly neurotic. She attaches quite undue importance to her condition, and can think of little else. Manj^ are peevish and irritable : a trouble to themselves and to all about them. If, as is often the case, they have sufficient money to live a lazy life, they spend most of their time in bed or on the sofa, and in travelHng to different health resorts. They never feel well or are comfortable, and to many of them life is a burden. The 3^ sleep badly, and can hardty get about at all. So marked is the neurotic element in many cases, that it is not surprising some observers have supposed it to be the cause of the condition. These cases form one of the worst classes of chronic invalids. There are a number, however, in which the other symptoms are well marked, but the patients are not in the least neurotic. I have met with several such cases where the patient refused to give way to the symptoms, but got about as usual, and lived a busy and useful hfe. The condition is one which is naturally depressing, and it is no cause for wonder, therefore, when the patient is not obliged to work, the symptoms are allowed undue prominence, and neurosis and hypochondriasis occur. Examina- tion of the abdomen, especially during an acute attack of pain, will often enable the colon — especially the descending colon and sigmoid — to be distinctly felt as a firm ridge. This is not because the colon is thickened, but because it is in a state of spasm, sometimes called enterospasm. If it could be seen, it would be found to be a firm tube with contracted walls. The Stools. — The character of the mucus differs considerably in different patients, and also in the same patient at different times. It may appear as clear slime like uncooked white of MEMBRANOUS COLITIS 131 egg, or as small clear lumps like tapioca. It may be present as whitish shreds, or strands, or in balls. Or again, it mav occur in long tubular casts, either complete or broken up into strips. Sometimes it is passed almost in the pure state, while at others it is more or less mixed and discoloured with fsecal material. If these shreds are washed they can be seen to consist of laminated layers of pure mucin mixed with epithehal cells and food particles. The stools are often pale in colour, owing to a deficiency in the secretion of bile. Blood is often present in small quantities, though it is necessary not to mistake blood from internal haemorrhoids for that from the colon. I have found blood to be present in about 60 per cent of cases. Intestinal sand is sometimes present. This curious material may exist in quite large quantities, and when first passed is of a reddish colour, almost exactly resembling ordinary sea sand, but afterwards becoming darker. One of the writer's patients passed as much as two ounces of sand in a day, but this is more than usual. In some patients it is always present in the stools, while in others it only occurs intermittently. Faeces containing this sand often cause considerable bleeding, from the scarifying action on the mucous membrane during their passage. Sand is generally only present in the more severe cases. In at least one case, the patient also passed uric acid gravel in the urine. The composition of this sand is approximately as follows : — ^Water 15 per cent, inorganic matter 51 per cent, organic matter 34 per cent. The inorganic residue contains salts of calcium, magnesium, phosphorus, iron, and also uro- bilin ; the chief inorganic constituent is calcium phosphate. Examination of the Patient. — This should be thorough, and should include a careful examination of the stools on several different occasions ; and, if possible, a specimen of faecal material and some urine should be sent to a competent pathologist for examination and report. Special attention should be paid to seeing if there is blood in the stools. The amount of undi- gested food is also important, and if there is diarrhoea it is a good plan to give some charcoal with the breakfast on one or two occasions, and ascertain when this is first seen in the stools. The abdomen should be examined as regards the presence of tumours, thickening of the bowel, spasm, etc. Also the stomach 132 CHRONIC MUCOUS OR should be percussed to ascertain whether any marked degree of visceroptosis exists. After this the patient should be made to stand up, and the abdomen be examined for weakness of the abdominal walls. The rectum should be examined, and a careful sigmoidoscopic search made to ascertain the condition of the pelvic colon. This last is essential ; otherwise the diagnosis is little better than guesswork, and if a local lesion exists, as it usually does, it will almost certainly be missed. Pathology and Etiology. Chronic mucous colitis is a condition the very name and description of which are based entirely upon its clinical sym- ptoms, and it is very difficult to deal with such a condition upon a purely pathological basis. I trust, therefore, that I shall be in part excused for any confusion of terms or misapplication of names which may occur in the attempt here made to so deal with it. Before going further it is necessary to consider Nothnagel's theory that the condition is a sensory neurosis. The Neurosis Theory. — Nothnagel maintained that no pathological lesion in the colon could be found, but he was. admittedly unable to see whether such a lesion was present or not, with the exception of a few cases in which the patient died from some intercurrent disease and a post-mortem examin- ation was possible. In five such cases, which will be referred to later, no lesion of the colon was found in one, but a lesion was present in the remaining four. In four others in which a post-mortem examination was made upon patients who had suffered from mucous colitis at some period during their hves, no lesion was found. These cases were reported respectively by Rugez, Edwards, Osier, and Jagic. Thus, out of a total of nine cases in which a post-mortem examination was made, no lesion in the colon was found in live. It must also be taken into consideration that the condition is not itself fatal, and that several of the patients had not had symptoms of cohtis for some time previous to death. Even as negative evidence this is not strong. The other fact which Nothnagel made much of to support his theory was that most of the patients are neurotic. But typical cases of chronic mucous colitis occur in which there is no neurosis ; on the other hand, we commonly see sufferers from chronic prolapsed piles or some similar ailment, who have MEMBRANOUS COLITIS 133 become markedly neurotic, but we should not think of arguing that the piles were caused by the neurosis. It is evident that Nothnagel's theory with regard to the causation of chronic mucous colitis rests upon the slenderest evidence, and that of a purely negative character. It is impossible to arrive at any satisfactor\' conclusion with regard to the pathology unless definite data as to the condition of the colon are obtainable. Until recently such data were only possible after a post-mortem examination following the death of the patient from some intercurrent disease. Lately, however, the surgeon has on many occasions been called to operate upon these cases, and an opportunity has thus been afforded of examining the colon during the progress of the operation. Also, within the last few years, the introduction of the electric sigmoidoscope has made it possible to examine the interior of the pelvic colon in such cases and to see the condition of its walls. I have collected eighty cases of this condition in which data ha\-e been obtainable, and it is on this evidence that the state- ments here made are founded. Hitherto the cases of chronic mucous colitis collected by different writers have been taken indiscriminately, and in the majority of them there is no evidence whatever of the condition of the colon. This is true of the collected cases of Hale White, Von Noorden, and Harrison, and these series, though of value from the clinical aspect, are useless from the pathological. In the series here given of 80 cases, only those have been taken in which either some lesion of the colon was found to be present, or in which such a lesion was more or less definitely excluded either by post-mortem examination or by operation. Cases in which a Post-mortem Examination was made. Rothmann . . . . An inflammatory condition of the mucous membrane of the colon was found. Abercrombie . . There was a chronic cystic condition of the whole mucosa of the colon. Hemmeter (2 cases). A histological examination of the wall of the colon showed chronic inflammation of the mucosa. Weigart. \ Osier. No pathological condition of the Edwards (2 cases). colon was discovered. Jagic. ) 134 CHRONIC MUCOUS OR Of the cases which I have collected, I will take those first in which no cause for the condition was discovered. There are 14 such cases. In four, no lesion was found, but blood was present in the stools in addition to the mucus. Now bleeding cannot occur without an abrasion of the mucous membrane or some pathological condition ; it is therefore certain that some lesion did exist in the colon in these cases, though at the operation nothing abnormal was noticed. In none of the remaining ten cases was the whole colon thoroughly examined, and they cannot, therefore, be taken as certain evidence that no lesion was present. In all the other 66 cases a definite lesion was known to be present. The nature of the lesion varied considerably. Cases. Adhesions and pericoHtis causing more or less kinking and obstruction. . . . . . 14 Enteroptosis of the colon . . . . . . 5 Chronic appendicitis . . . . . . 5 Inflammation or displacement of the uterus or appendag^es . . . . . . . . 2 Previous operations upon the abdomen and involving the colon . . . . . . 2 Chronic inflammation of the colon . . . . 30 Cancer . . . . . . . . . . 7 Fibrous stricture of sigmoid . . . . i In two cases there was old pelvic cellulitis and the sigmoid flexure was involved in the adhesions. In one case an abscess had burst into the colon two years previously, and much thickening round the sigmoid flexure could be felt. There was also blood in the stools. One patient had had a previous attack of gall-stones, accompanied by local peritonitis in the neighbourhood of the gall-bladder. In two, the colitis began after a severe attack of gastric ulcer from which the patient had recovered without operation. One of these patients, a woman, age 45, was subsequently operated upon, and extensive adhesions were found binding the stomach, great omentum, and transverse colon so firmly to the anterior abdominal wall, that they could not be separated without serious risk of tearing the bowel. One patient had had a large abscess in the back of the pelvis opened and drained through the abdominal wall, and the colitis dated from this. ■ In three. MEMBRANOUS COLITIS 135 the sigmoid flexure was found to be bound down and kinked by a band of adhesions. In several of the cases there was definite thickening of the cohc wall, or chronic inflammation of the mucosa, in addition to the adhesions. The adhesions seem indirectly to cause the increased mucus and membrane in the stools by kinking or narrowing the colon. This results in the faecal contents passing slowly, or being temporarily retarded, with consequent local irritation and inflammation of the mucosa. Enteroptosis is only an indirect cause of colitis, and should rather be considered as giving rise to the constipation to which the colitis is secondary. Some of the worst cases of membranous colitis that I have seen, have been due to enteroptosis. Not only is the mesocolon lengthened, allowing the colon to fall into the lower part of the abdomen, but the colic wall itself shows well-marked changes: it is thinned and dilated, often to a con- siderable extent. The normal pouching is much increased, and the wall bulges between the longitudinal muscle-bands. If the interior of the sigmoid is examined with the sigmoidoscope, the walls can be seen to bulge inwards in such a way that they tend to prolapse into the part of the bowel immediately below. In two of my cases, both women, the centre of the transverse colon lay in Douglas's pouch ; and in one, the centre of the sigmoid flexure could reach the edge of the liver. As one would naturally suppose, severe constipation accompanied the condition. Chronic Appendicitis. — There has been much discussion as to the relationship between this and chronic colitis. That the two conditions are frequently associated there can be no doubt. Colitis not uncommonly results from chronic inflammation of the appendix, or the two may occur together, the one complicating the other. There is very positive evidence that chronic appendi- citis may cause colitis. Mr. Lockwood has recently recorded three cases of colitis in which the removal of a chronically inflamed appendix resulted at once in the disappearance of all the cohtis symptoms ; in each of the cases the appendix contained septic material which periodically escaped into the caecum. In five of my collected cases, a chronically inflamed appendix was found, and its removal resulted in the disappear- ance of the colitis. In three of these, large mucous casts had 136 CHRONIC MUCOUS OR previously been passed, and this is of interest, because some writers attempt to draw a distinction between mucous and membranous colitis. A certain amount of colitis must almost invariably accompany chronic appendicitis, and as Lockwood has pointed out, it is common to find a certain amount of inflammation of the ascending colon when operating for appendicitis. Chronic appendicitis can apparently give rise to colitis in three ways : — 1. By the inflammation spreading from the appendix directly to the caecum, ascending colon, and transverse colon ; we have evidence of this in many cases of chronic appendicitis. 2. As a result of appendicitis, adhesions may form between Fig. 43. — Malignant tumour in the sigmoid flexure, which gave rise to symptoms of colitis as seen and diagnosed by the sigmoidoscope. the appendix or caecum and other parts of the colon, usually the sigmoid. These adhesions, by constricting the lumen of the bowel, either directly or by the formation of kinks and abnormal angles, may result in a local inflammation of the mucosa, which spreads to other portions of the colon. 3. The inflamed appendix acts as a septic focus which is constantly discharging septic material into the colon. It seems as reasonable to consider this a cause of colitis as to consider gastric ulcer and gastritis a result of septic conditions of the mouth and teeth. Malignant Disease. — In seven of the cases the colitis was found to be due to cancer in the colon. In all of them the growth was in the sigmoid flexure. In three the membranous casts supposed PLATE III Fi^. A. Chronic Colitis. — Sigmoidoscopic appearance of the pelvic colon in two cases. {Aiit/wr). MEMBRANOUS COLITIS 137 by some to be typical of the neurotic form of colitis were found in the stools. In all of these cases the condition had been diagnosed as chronic mucous colitis. In six, the growth was disco\-ered on examining the bowel with the sigmoidoscope, and in one case appendicostomy was performed for supposed chronic colitis, the patient subsequently developing obstruction, which drew attention to a cancer of the sigmoid. Chronic Inflammation of the Colon. — In thirty of the cases the cause was found to be a chronic inflammatory condition of the mucosa. In most of these the condition of the mucosa was directly examined by means of the sigmoidoscope. In all, a true colitis was present, but the type of inflammation differed. Hypertrophic Colitis. — In this condition the mucous mem- brane is paler than normal, and considerably swollen, due to submucous oedema. The mucosa tends to lie in folds or concentric rings, and to prolapse into the lumen in a character- istic manner. The bowel wall appears to be redundant, and somewhat resembles a series of short intussusceptions at the part under observation. This condition is associated with excessive secretion of a thick glairy mucus, which can be seen sticking to the bowel wall in long bridges or loops. The reaction of this mucus is sometimes acid. Granular Colitis. — This is present in a number of cases. The granular appearance of the mucosa is often very marked, and gives it a curious appearance as the light is reflected from each little swelling. This is due to inflammation of the follicles in the mucosa ; each follicle is swollen, and projects above the general surface. The condition is a pre- cursor of follicular ulcerative colitis, and it is not uncommon to find that some of the follicles have broken down and formed ulcers. The mucosa is inflamed and often of a dusky- red colour. In several of the cases in which I have been able at a subsequent operation to examine the bowel wall, I have found it much thickened, and in one there was also some enlargement of the lymphatic glands in the mesosigmoid. (See Plate III.) Chronic Catarrhal Colitis. — For want of a better, this name must be used, as there is no particular feature to differ- entiate this form of inflammation. Here the whole visible mucous membrane can be seen to have lost its normal glistening appearance, and to be much redder than the normal mucosa. In a well-marked case the appearance is as if the surface had 138 CHRONIC MUCOUS OR been rubbed off with sand-paper. The surface bleeds readily if touched, and apart from this, small bleeding areas can be seen. Here and there patches of yellow membrane-like mucus can be seen adhering tightly to the mucosa ; and if these are wiped off, the subjacent mucosa will bleed. The inflammation is not uniform, but is always best marked at the apices of the folds, and on the upper surfaces and edges of the valvulas conniventes. The appearance of the mucosa in cases of colitis bears a close and remarkable resemblance to the inflammatory conditions of the throat. I have seen the exact appearance of granular pharyngitis in the sigmoid flexure, and in many cases of colitis which I have examined, the appearance irresistibly reminded me of what is usually described as a septic sore throat. The condition of the mucosa in colitis varies much, even in the same case. At one time the mucosa will look almost normal, while at another the conditions described may be seen. The condition is a chronic one, but the degree of inflammation varies very much from time to time. Though for purposes of description it is convenient to divide up the types of inflammation seen in colitis, it is not unusual to find more than one type present in the same case. Ulcers in the mucous membrane are also often seen in colitis, but they will be dealt with in considering ulcerative colitis. From the statistics here given it seems safe to conclude that, in the great majority of cases of so-called chronic mucous or membranous colitis, a definite pathological cause for the symptoms exists, though these causes are of widely varying chaarcters in the different cases. B. V. Beck, in Germany, has come to a similar conclusion from the study of a large number of cases. A careful study of the cases which I have collected, and of the pathological data obtainable in cases of chronic mucous or membranous colitis, leads inevitably to one conclusion, namely, that mucous and membranous colitis, as ordinarily described in text-books and medical treatises, is not a disease, and has no claim to be considered as a clinical entity. It is clearly a collection of symptoms which, from want of better knowledge as to the pathology of the colon, have been described as a disease, whereas in fact these symptoms may be due to many different pathological conditions of the colon, of widely different characters. MEMBRANOUS COLITIS 139 The name mucous or membranous colitis should not be used, as it depends upon the presence of mucus in some form or other in the stools ; and as I have already shown, there is excess of mucus in a great variety of different patho- logical states of the colon ; and further, the form which the mucus takes, whether shreds, casts, or membrane, is of no real or pathological importance, membrane and casts being merely a rarer form in which the mucus may exist in the dejecta. (See Chapter II.) The name chronic colitis should be retained, but should be used only to designate those cases already described in which a definite chronic inflammatory condition of the mucous membrane of the colon is known or supposed to be present. The word colitis means inflammation of the colon, and is therefore correct as applied to those cases, but is not correct if the condition is a neurosis, or if due to pathological conditions not dependent upon inflammation. Previous writers have argued that chronic colitis is a neurosis because in certain instances no lesion can be found in the colon, and it cannot be denied that there are such instances, though they are rare. It seems most reasonable to explain such cases as being those in which imperfect observation has failed to find the cause, which nevertheless did exist, rather than to assume that they are a special class in which there is no patho- logical lesion. But even if we admit that cases occur without any pathological lesion in or around the colon being present, it is not correct to describe these as colitis, and thej^ should not be included. Treatment. Non-operative Treatment. — If the patient is seen during an attack, it will be necessary first to relieve the acute symptoms, and especially the pain, before proceeding to deal with the colitis. The indication is to empt}' the colon of the contained mucus. The plan I have found most satisfactory is to first give a hj'podermic injection of morphia, in order to reHeve the spasm and pain, and then to administer a large olive-oil enema. This should be given very slowly, with the patient in the left Sims position, and about a pint should be injected. At least fifteen minutes should be occupied in giving the enema, and when it is all in, the patient should assume the knee-elbow position for 140 CHRONIC MUCOUS OR a few minutes to allow the oil to run well up into the colon. An hour or two later, a plain warm-water enema of about two pints should be given. This will generally result in bringing away the mucus, and will terminate the attack ; if not, it should be repeated. The non-operative treatment of chronic mucous colitis consists in getting the mucous membrane of the colon back into a normal state. For this purpose nothing seems better than injections of olive oil. The oil should not be used as an enema, but should be retained as long as possible, in order that it may act as a dressing to the inflamed mucous membrane. I order from a half to one pint of warm olive-oil to be injected very slowly into the rectum at bedtime. After assuming the knee-elbow position for a few minutes in order that the oil may get well up the colon, the patient should remain quite quiet and, if possible, retain the oil till next morning. If it is properly administered, most patients will easily retain half a pint, and I have known several who, after they had become accustomed to the injections, could retain a pint all night. Next morning a warm water enema is administered. Under this treatment the colitis often quickly clears up, and the mucous membrane soon assumes a healthy appearance. Sometimes it will be found that some stimulating application is needed, as the mucous membrane remains in a chronically inflamed condition in spite of the oil. The best injections under such circumstances are protargol or argyrol in ^ per cent solutions. Nitrate of silver should never be used, as it causes severe burning pain and does no more good than the albuminates of silver, which are painless. When protargol is used, it should be given in place of the oil, and the bowel should first of all be washed out with warm water. The injections should be made with a No. lo soft rubber catheter and a glass funnel, not with a syringe. It is most important in cases of chronic colitis to treat the constipation which almost invariably accompanies it. While the oil is being administered, the bowels will act without difficulty, however, and no aperients should be given. Personally, I believe it is better not to administer aperients at all in cases of chronic colitis if they can possibly be avoided, as they help to keep up the condition. The best aperient is castor oil, if one has to be given. Dr. Hale White believes in treating colitis by half-ounce doses of castor oil administered MEMBRANOUS COLITIS 141 on waking in the morning. The only other aperients which are allowable are sulphate of magnesia and small doses of cascara. Metallic aperients, such as calomel, should on no account be given, because they increase the inflammation of the mucosa and aggravate the disease. Among the drugs which have been advocated for cohtis, mention must be made of belladonna. This often has a good effect in preventing the spasm of the colon which is so common. The following antispasmodic mixture I have often found to do good in cases of colitis : — Tinct. Hyoscyami 3ss Tinct. Belladonnae .. ni^-j Sodee Bicarb. . . gr. XX Tinct. Zingiberis . . . . Tl[xv Spt. Chloroformi . . . . ll[xx Aq. Menth. P:p. . . . . ad.3J Misce. One ounce three times daily. Arsenic in full doses is also recommended, and seems to do good in some cases. Diet. — The old-fashioned treatment for chronic cohtis was to feed the patients with milk and easily digested slop dietary, with the object of keeping the colon empty. This is a mistake ; the normal colon is never empty, and there is no object in trv'ing to keep it so. Moreover, these patients require feeding up, in order that their general condition mav improve, and it is most important the}- should be given a full diet. Von Noorden has, I think, proved that the old plan was a mistake ; and patients treated with his form of dietary certainly do much better, and the colitis clears up more quickly, than was the case with the old method. Von Noorden's principle is to give a full diet containing an excess of indigestible residue : that is to say, cellulose and fibre. The patient should have plenty of vegetables and fruit, brown whole-meal bread in place of white bread, and a small amount of brown meat. The diet should be a full one, in fact as much as the patient can eat. The result is, of course, to cause copious faeces, owing to the large amount of indigestible material in the food. If such a diet were given alone, it would result in hard, firm stools, which it is particularh' desirable to avoid : to get over this, therefore, a sufficient quantity of fats must be added 142 CHRONIC MUCOUS OR to ensure the faeces not becoming formed. The ahmentary canal can only absorb a very hmited amount of fat, and if, therefore, an excess is given, the remainder will pass out in the fasces, and, as fats are liquid at body temperature, will prevent the faeces becoming hard, and keep them soft and unirritating; The amount of fat required must be gauged by the stools, which should be about the consistency of ointment, and should be quite unformed when passed. The fat is best given as butter, milk, fat bacon, and cream. The addition of about two ounces of thick Devonshire cream to the diet will in most cases produce the desired effect upon the stools. In some patients the excess of fat causes biliousness and indigestion, and on this account they are unable to continue taking it. When this is the case petroleum should be substituted for the fat. Petroleum, in the form of " Lenitol " (Rouse & Co.), or the hquid petroleum of the B.P., can easily be taken by the mouth, as it is quite tasteless, and beyond the greasy sensation is not unpleasant. This is not absorbed in its passage along the alimentary tract, and all passes out as it goes in. If the correct quantity is given, it absolutely prevents any solidification of the faeces. In most persons, three teaspoonfuls of "Lenitol" by the mouth in the 24 hours will render the faeces quite soft and unirritating, but the exact quantity required must be ascertained by experiment. Fat is, however, better than petroleum when it can be taken, as it helps the patient to increase his weight, which is very desirable in most cases. The first effects of Von Noorden's diet are often to cause discomfort from flatulence and indigestion. In some, it may even cause nausea. This is hardly surprising, considering that the patient as a rule has been living for some time on a minimum of food, and has no appetite. These unpleasant symptoms, however, soon pass off, and he begins to see the benefit of the changed dietary. The weight rapidly increases, the bowels begin to act regularly, and there is a steady improvement in the general health. In order to overcome the initial discomforts which often result from the diet, and to prevent the patient giving up the treatment, it is advisable to keep him in bed at the beginning, and to order gentle abdominal massage. The massage should be for about ten minutes, an hour after each meal, and along the line of the colon. This will quite prevent any discomfort, and will greatly assist the action of the bowels. MEMBRANOUS COLITIS 143 I have often seen patients, who for years had never had an unassisted action of the bowels, get two natural motions a day directly this treatment is adopted. As a rule they quickly get accustomed to the diet, and are able to dispense with massage in ten days or a fortnight : It should be continued for some considerable time, not stopped directty the symptoms disappear. No aperients should be allowed. Operative Treatment. — This condition, like so many others, is one of those in which, purely medical treatment having failed to give relief, the aid of surgery has of recent years been called in. Hale White has stated that in many cases a cure cannot be expected from medical treatment, and that in one-third no alleviation of the condition results from it. Beck goes further, and says that none of the cases treated medically are cured. ^^'hile Beck certainly overstates the case, there is no doubt that in a considerable number of cases the surgeon is called in because medical treatment has failed to do any good. This failure must be to a considerable extent attributed to the fact that the cause of the condition has not been found, and that, in consequence, the appropriate treatment has not been adopted ; the first essential of treatment in these cases being a correct diagnosis as to the underlying cause of the symptoms. As I have already shown in discussing the pathology, the cause is in many cases one which can only be dealt with bv surgical operation. I shall here only discuss the treatment of cases of real chronic cohtis (i.e., where an inflammatory condition of the colon exists), as in the others the treatment naturally comes under other headings, according to the pathological condition found, the obvious indication being to remove the cause when- ever possible ; this may be a chronicall}- inflamed appendix, adhesions, cancer, disease of the uterus or appendages, etc. In order to make a correct diagnosis, an exploratory laparotomy may be necessary, and in this case the operator will proceed to deal with whatever cause is found, or to do whate\'er operation he considers advisable. The first pubHshed operation for chronic membranous colitis was done at the suggestion of Dr. Hale White by Mr. Golding Bird in 1895, though apparently the first operation performed for this condition was by Mr. Keith in 1894. In both the operation consisted in estabhshing an artificial anus 144 CHRONIC MUCOUS OR on the right side, in order to deflect the faecal current and give rest to the colon. In considering the surgical treatment, we have to bear in mind that the condition is not a fatal one and in no way threatens life, but calls for treatment on account of the disable- ment and distress it causes. Surgery has attempted to cure the condition in two ways : — 1. By deflecting the faecal current through the colon, so as to give the latter complete rest. 2. By establishing an opening through which the colon can be constantly washed out and kept clean. Of these, the first was the method adopted in all the earh' cases operated upon. A right-sided colotomy or caecostomy was performed, and the faeces thus prevented from passing along the diseased colon. In the first case operated on by Mr. Golding Bird, the patient was much benefited b}^ the operation. The colotomy opening was closed in seven weeks, and the patient appeared to be cured of her .colitis. But five weeks later she died suddenly from peritonitis, the cause of which was not discovered. I have found records of six cases in which an artificial anus was established on the right side, in five cases the caecum being opened and in one a right lumbar colotomy being performed. In all these the symptoms rapidly and completely subsided after the colon was put at rest. In all of them the symptoms had been severe, and had resisted all other forms of treatment. The artificial anus was kept open for varying periods, from six weeks to three years. It was found that if the opening was closed too soon, the symptoms were liable to return. In one of Mr. Golding Bird's cases the colotomy was closed in a year, and the patient remained well for six years from the original operation, but then relapsed. In two cases, the patient was quite well and had had no relapse four years after the operation ; the others were well up to periods less than this. One died, as already mentioned. As regards, therefore, a cure of the colitis, right inguinal colotomy or caecostomy gives very good results, especially if the opening is maintained for some time ; Hale \Miite advises that it should be left open at least a year. The operation is, however, not a satisfactory one, and has been but little adopted. A right-sided colotomy is a most objectionable MEMBRANOUS COLITIS 145 operation to the patient ; the faeces are fluid and cannot be properl}- controlled, the skin becomes excoriated, and most patients would prefer the colitis to the discomforts which necessaril}' accompan\' such an operation. The opening can be closed again, but must be left open for many months if it is to be of any use. The closure is not, moreover, always an easj^ matter, and in several of the cases two, and even three, operations have had to be performed before the opening could be closed. To get over these objections, and still give rest to the colon, ileo-sigmoidostomy has been performed with the object of short- circuiting the colon. This has been done successfully in several cases. B. V. Beck has performed it for chronic colitis in six cases. The results w^ere excellent in five, but in the sixth the patient died as the result of a Murphy's button having been used for the anastomosis. This operation is the same as that which Lane has performed for constipation, and it is possible that some of his cases were of the same nature. Ileo-sigmoidostomy is much to be preferred to a right-sided colotom\', but is severe considering the nature of the malady, and has the further objection that it permanently short-circuits the colon, and the normal course for the fsces cannot afterwards be re-estabhshed. There is, however, considerable difference of opinion as to whether this is an objection or not. Also, in many cases the rectum and sigmoid flexure are involved in the disease, in fact are often the most diseased, and consequently the operation will not short-circuit the entire diseased area. Ileo-sigmoidostomy is, moreover, for other reasons an unsatis- factory operation, but this will be discussed in considering that operation. Left inguinal colotomy has also been done ; but this operation has nothing to recommend it, as it does not get above the disease and cannot, therefore, do much good. The objections to a right-sided artificial anus in these cases were early recognized, and the plan of making a valvular opening into the cscum, through which the faeces would not escape, but through which the colon could be effectualh- washed out, was tried. Gibson was one of the first to perform this operation, and it proved quite satisfactory as regards a cure of the cohtis. Except in exceptional cases, however, it has been replaced by the operation of appendi- costomy, by which the same object is more readily attained. 10 146 CHRONIC MUCOUS OR Appendicostomy has none of the objections of right-sided colotomy, and the results of this operation in the treatment of chronic cohtis seem to be equally satisfactory. The operation is practically free from risk, does not prevent the patient from attending to his ordinary occupation, and does not cause any discomfort or even inconvenience. It is therefore a suitable operation in these cases. I have collected several cases in which appendicostomy was performed for this condition. Case. — A man, aged 35, was under my care in St. Mark's Hospital in 1907. For fifteen months he had been suffering from repeated severe attacks of pain in the abdomen, accompanied by the passage of much mucus. He had been unable to follow his occupation, and a long course of medical treatment had given him no material relief. Appendicostomy was performed and the colon washed out daily with two pints of boracic lotion, and later with the same quantity of water. Previous to operation, the colon could be seen on examination with the sigmoidoscope to be much inflamed, and in several places ulcers were present. After the operation his symptoms quickly cleared up, and a month later all signs of inflammation in the colon had disappeared. He left the hospital and continued the irrigations for six months ; meanwhile, however, he returned to his occupation. Three months after operation he had gained over a stone in weight and felt quite well. A year after the operation he was still quite well, and had had no return of the colitis. The opening of the appendix caused him no trouble, and he was advised to keep it open for some months longer. When last seen a few months ago he was quite well, and the opening had been allowed to close. Case. — A lady, aged 32, had for eight years been a complete invalid owing to severe intermittent attacks of so-called membranous colitis. She spent most of her time in bed, was highly neurotic, and had lost weight. She had been treated by different dietaries, and douches, medicine, and electricity, but without any improve- ment. Sigmoidoscopy showed chronic inflammation of the mucous membrane. I performed exploratory laparotomy, which revealed some thickening of the bowel wall and adhesions binding down the sigmoid flexure. The latter were divided and appendicostomy performed. The colon was daily irrigated with water, and the patient continued the irrigation for herself after her return home. She rapidly im- proved and put on weight. Six months later she was quite well, and there had been no further attacks of colitis and no mucus or membrane in the stools. I heard from her again over a year after the operation ; she was quite well and had had no return of the colitis. MEMBRANOUS COLITIS 147 This case is of particular interest, as the patient previous to operation was very bad, and the question of making an artificial anus on the right side had been discussed. A complete cure of the condition resulted from the operation, and has remained permanent up to the present time. I have collected in all twenty cases in which appendicostomy was performed for chronic colitis. These include six cases of my own, of which five were operated upon by myself, and one by another surgeon before I saw the case. There are also fourteen cases collected from medical records. The results in these cases may be tabulated, as follows : — Cases. Results. Remarks. Author 6 Cured 4 All well over a year Impro\ed I later. There were No better I slight temporary relapses in two cases. Edwards I Cured Tuttle Cured Improved I I WiUis I Cured Keetley 3 Cured 2 Moynihan I Cured Armour I Cured Stretton 3 Cured Improved No better I I I Grey T Recovered Slight relapse two years later. Pringle I No better In 13 out of the 20 cases the patients were cured of the colitis, and no relapse is stated to have occurred. In three the patients much improved, but one or more slight and temporary relapses occurred during the following two years. In three the patients were no better after the operation, and one was too recent to form any opinion. The three cases in which there was no improvement are worth recording in detail. The first was a lady, aged 32, who was sent to me by her medical attendant with a history that 148 CHRONIC MUCOUS OR appendicostomy had been performed for chronic cohtis a year previously, but that she had not been any better since the operation. A careful examination of the bowel with the sigmoidoscope showed no signs of colitis, and I came to the conclusion that she had some lesion in the hepatic flexure of the colon, probably adhesions from an old gastric ulcer. She was averse to any further operation. The second is a case, reported by Mr. Seton Pringle,* of a labouring man with severe membranous colitis, on whom appendicostomy was performed. No improvement followed the operation, and six months later he was as bad as before. An examination of the bowel with the sigmoidoscope showed no colitis. Mr. Stretton reported the third case. The patient was an elderly woman, on whom appendicostomy was performed for symptoms which were attributed to chronic mucous cohtis. No improvement followed the operation, and it was subsequently discovered that there was a malignant growth in the sigmoid flexure which had been the cause of the symptoms. It thus seems probable that the cases where no improvement follows appendicostomy are those in which a wrong diagnosis has been made in the first instance. In some of the cases in which relapse has occurred, this has apparently been due to the opening being closed too soon. From these instances, few as they are, it may, I think, be fairly concluded that in appendicostomy we possess a very good and useful means of treating bad cases of true chronic colitis which will not respond satisfactorily to medical treat- ment ; by it we may expect to obtain a cure of the condition without serious risk, and without inconvenience, even in the worst and most protracted cases. I purposely say true chronic colitis, for if the operation is performed without a correct diagnosis having previously been made, and therefore on patients in whom the symptoms are due to some gross lesion of the colon, a satisfactory result cannot be expected. Where there is chronic inflammation of the colon,, a good result may confidently be expected from the operation,, and where chronic colitis is associated with, or has resulted from, a gross lesion, good results will follow, providing the lesion is removed or remedied at the same time. * Brit. Med. Jour. 1908, vol. ii, p. 1713. MEMBRANOUS COLITIS 149 It is certainly advisable that the opening should not be closed too hastily, and a year, or even longer, is not too much to allow before permanently closing the appendix. The disease is one which is particularly liable to relapse, even after long periods of complete immunity from all symptoms ; and as the operation cannot readily be repeated, it is advisable to retain the opening until all likelihood of a relapse has passed. If in nine months after the operation there has been no recurrence of symptoms, the irrigations may be discontinued, and the opening allowed to close of itself. This it will do in a few days by the formation of a thin skin over the externa opening. In this condition it will not cause the slightest inconvenience, and if later there should arise the necessity to re-open it, this can readily be done by the introduction of a probe, because the appendix itself will not have closed. Many people seem to have an idea that appendicostomy results in an objectionable condition somewhat like that following colotomy. This is, however, not the case. If the operation has been properly performed, there is nothing but a small and depressed scar in the abdominal wall, from which neither faeces nor mucus escapes, and over which in most cases it is not necessary to wear anything except the ordinary underclothing. The patient should be quite unaware of the presence of any opening except when using it for irrigation, and it does not prevent the patient living an ordinary life. For details of the operation the reader is referred to the chapter on appendi- costomy. All kinds of fluids have been used for the purpose of irrigating the colon, and in three cases which have come under my observation, symptoms of poisoning have resulted. Two were cases of boracic acid poisoning, and one of carboluria from the use of lysol. Antiseptics do not seem to be necessary, and some of the best results have been attained where nothing but plain water was used ; when patients have to do the irrigation for themselves, this is much to be preferred. Silver compounds, such as argyrol or protargol, o'5 or i per cent, have been em- ployed, but are probably unnecessary. In conclusion, it may be said that the first essential for successful treatment is a correct diagnosis : this necessitates an examination with the sigmoidoscope, and sometimes may require an exploratory laparotomy. In true chronic colitis 150 CHRONIC COLITIS appendicostomy should be the operation of choice in all cases where medical treatment has failed. ENTEROSPASM. This is the name given to a condition in which there is a spasmodic contraction of the circular muscle-fibres in some portion of the colon. The contraction of the colon is localized to one spot, and varies from one to several inches in length. So intense is the constriction, that the bowel lumen is partly or completely closed, and symptoms of intestinal obstruction occur. The condition is comparable to asthma and spasmodic stricture of the urethra. It is only recently that anything positive has been known about this curious condition, but before it was described, many surgeons had met with cases in which a patient with all the symptoms of intestinal obstruction had been operated upon, and on opening the abdomen no obstruction of any sort was discovered after the most careful search. In several of such cases the upper part of the colon and small bowel were found distended, and the lower portion of the colon collapsed and empty ; yet no obstruction or possible cause of obstruction was to be discovered at the point where the distended and collapsed bowel joined. These cases were a mystery, but it now seems probable that they were in reality instances of enterospasm. Although enterospasm was first suggested as an explanation of these and similar cases on purely negative evidence, we now have positive proof that the condition actually occurs. In not a few cases the spasmodic stricture has been seen and handled during an operation for the relief of intestinal obstruction. Perhaps the best instance occurred in the practice of my colleague, Mr. Swinford Edwards. The patient was a woman with a history of several attacks of partial obstruction in the colon. Careful palpation of the abdomen revealed the presence of a hard swelling apparently in the sigmoid flexure, and it was thought that she had a tumour obstructing this portion of the colon. It was decided to perform laparotomy, and, if possible, remove the growth. On opening the abdomen, Mr. Edwards was unable to find any tumour, and the sigmoid flexure appeared to be normal. While, however, he was examining it, a contrac- tion about two inches in length appeared in the sigmoid flexure. ENTEROSPASM 151 The contracted portion was hard, and might easily have given the impression of a tumour when felt through the abdominal wall. The contraction disappeared and then re-appeared in the same place while the colon was under observation. I have also had a similar case in my own practice. The patient was a woman, aged 39, who was admitted into the hospital for attacks of intense abdominal pain and symptoms of a severe colitis. A sausage-shaped tumour about two inches long could be felt in the region of the sigmoid flexure. There was constant diarrhoea, with stools consisting of blood and mucus. I at first thought there was a growth in the bowel which had caused the symptoms, but a careful examination revealed the fact that the tumour was only present during attacks of abdominal pain, and that when the patient was examined between the attacks no tumour could be felt. This was verified by repeated examinations, and we came to the conclusion that the supposed tumour was due to a localized contraction of the colon. The affected portion of colon always occupied the same position, and was appearently of the same size. There was tenderness on pressure over this spot, and in view of this, and the presence of blood in the stools, it seemed probable that the enterospasm was set up by an ulcer in the colon. The patient was treated by dietary and full doses of belladonna. She recovered, and left the hospital free from the attacks of pain from which she had previously suffered. Etiology. The patients are nearly always women between the ages of thirty and fifty, and usually of a markedly neurotic type. There is a history of hysteria, or other symptoms ascribed to neuras- thenia, in almost all cases. The condition is closely associated with chronic colitis, and I have never met with a case in which there were not well-marked symptoms of colitis. There is good reason to suppose that the spasm is set up by some local lesion in the colon. Thus the condition is always accompanied by a chronic colitis. Moreover, in all the cases which I have seen or been able to find recorded, there has been blood in the stools, which is definite evidence of ulceration somewhere in the bowel. The fact that the spasm is locahzed to a particular portion of the bowel also strongly suggests a local irritative cause. 152 ENTEROSPASM The condition is essentially a chronic one, and there is usually a history of attacks of abdominal pain dating back for several years. Symptoms. The most marked symptom is severe abdominal pain. '^ This usually occurs in paroxysms, which commence suddenly without apparent cause, and after lasting for a period varying from a few hours to several days, pass off equally suddenly. The pain while it lasts is very severe, and often closely resembles that which occurs in the early stages of peritonitis or acute intestinal obstruction. It may also be easily mistaken for renal colic. It is usually well localized to that portion of the abdomen in which the contracted area of colon lies. Vomiting not infrequently accompanies the pain, and may be well marked. If the spasm continues for any length of time, the abdomen becomes distended, there is more or less complete constipation, and the patient's condition becomes typical of acute intestinal obstruction. Either as the result of the administration of morphia, or naturally, the attack suddenly terminates, the bowels act, the pain stops, and in a few hours the patient is quite well again. If the abdomen is examined during an attack, it is often possible to feel the contracted area of colon, which is most commonly situated in the descending colon or sigmoid flexure. In addition to the symptoms caused by the enterospasm, there are usually those of a chronic colitis. The stools contain much mucus and often blood. There is constipation alternating with periods of diarrhoea, and all the other symptoms usually associated with a chronic colitis. In the more severe cases faecal vomiting and visible peristalsis may also be present. The diagnosis is extremely difficult. The condition may be suspected, but if the patient is first seen during an attack it will be practically impossible to be certain that the condition is due to enterospasm. The greatest difficulty arises in deciding as to whether or not an operation shall be performed. Usually the condition, though very distressing, is not serious, but the following case, reported by Dr. Pendred,* terminated fatally. Case. — ^The patient was a querulous, excitable woman, aged 57. For the preceding three years she had suffered from time to time Brit. Med. Jour., May 29, 1909, p. 1292. ENTEROSPASM 153 from colic, with vomiting and diarrhoea. Latterly these attacks had become very frequent and severe. The urine showed a trace of albumin, and she complained of frequent micturition. During the next two months, in spite of energetic treatment, she had much colic, and had plainly emaciated. A copious bleeding from the rectum occurred about this time. Month after month she continued to waste, and had constant vomiting attacks. Constipation alternated with diarrhoea, which latter somewhat relieved her pain. In July, 1905 — ten months after she was first seen — she was nearly bedridden with colic, coming on every few minutes, accompanied by tremendous borborygmi. Visible peristaltic waves passed across coils of intestine from left to right every few minutes, as though the intestine were endeavouring to overcome some obstruction. By the end of this month her condition was pitiable, and she had to be kept constantly under the influence of morphine. The pain was almost constant night and day. The vomit now became stercoraceous, hiccough supervened, and the bowels were confined. On July 29th the abdomen was opened, but at first nothing amiss could be found. At one point the distention of the gut suddenly ceased, and the distal portion was flat, toneless, and of a paler colour, so that it was thought the obstruction had been discovered. WhUst the bowel was being watched, the collapsed gut began to fill out again, just as it had appeared to do through the abdominal wall. Three days later her condition was as bad as ever, the gurgling, peristalsis, pain, and sickness, with occasional haematemesis, being nearly continuous. She died in the middle of September. A post-mortem examination of the abdomen showed that every organ, though wasted, was macroscopically healthy. The intestine was partly opened up, and presented a normal appearance. Treatment. The obvious treatment, if the condition can be diagnosed, is to give a full dose of morphia and belladonna to allay the spasm. This will usually quickly terminate the attack. Placing the patient in a hot bath will also often have a similar effect. But the key to the situation is the diagnosis, and it is often impossible to be certain that we are not dealing with a strangu- lation of the bowel. If the condition can be diagnosed, further attacks may be prevented b\" treating the colitis and by administering belladonna in full doses. 154 Chapter XII. ULCERATIVE COLITIS. Until quite recently ulcerative colitis was a disease of the post-mortem table ; it was seldom diagnosed during life (with the exception of tropical dysentery), and no attempt had been made to deal with it by operative surgery. It is now, however, beginning to be recognized that ulceration of the colon may be dealt with successfully, and already there are a number of cases on record in which the disease has been cured by operation, which otherwise would almost certainly have ended fatally. The subject of ulcerative colitis is surrounded by many difficulties. Most of our knowledge of the morbid appearances is derived from post-mortem examinations, in which from the nature of things only the terminal and most severe characters of the disease can be studied. The confusion which exists between ulcerative colitis and tropical dysentery is as yet far from being cleared up, and there are those who still assert that all cases of ulcerative colitis are examples of tropical dysentery. Ulceration of the colon resembles that of the skin, inasmuch as it may result from a great many different conditions and occur in many different forms. Thus it may arise secondarily to some constitutional trouble, such as Bright's disease, gout or plumbism. It may result from a specific infection, as in amoebic dysentery, Shiga's bacillary dysentery, enteric fever, tuberculosis, and possibly syphilis. It may occur from malignant disease, or as the result of hardened and long- retained faecal masses, such as the ulceration caused by a stercolith, or in the dilated bowel above a stricture. It may follow damage to the blood-supply of the colon, as in some cases of cirrhosis of the liver and in embolism of the mesenteric arteries. Or it may result from trophic changes due to inter- ference with the innervation of the colon ; two such cases are ULCERATIVE COLITIS 155 recorded by Dr. Hale \Miite, in which the patient had a fractured spine and paraplegia. Much of the confusion which surrounds the subject has arisen from the fact that investigators have often failed to sufficiently recognize the great number of different causes of ulceration in the colon, and, confusing several together, have attributed all to some specific cause. Ulcerative colitis has been considered so fatal a disease, apart from tropical dysentery, that some writers have main- tained it cannot be recovered from, and that the reported cases of recovery were not true ulcerative colitis. This is a not uncommon error when a disease is studied only upon the post-mortem table and there is no other means of arriving at a correct diagnosis. A study of the recorded cases would Fig. 44. — Ulcers in the sigmoid flexure in a case of chronic constipation. certainly lead to the conclusion that the disease, except in its epidemic form, is practically always fatal. The sigmoidoscope, however, has made it possible to diagnose ulcerative colitis with certainty without a post-mortem examin- ation, and it is now obvious that the disease is by no means incompatible with complete recover}^ and with early diagnosis and suitable operative interference there is good reason to hope that much may be done to materially lower the mortality. Etiology. The disease is one of early adult life ; thus, out of my series of 60 cases, the average age is 37. It apparently does not occur in children, with the exception of follicular colitis. 156 ULCERATIVE COLITIS The sexes appear to be equally affected ; out of the total of 177 cases collected from different London hospitals at the time of the discussion on ulcerative colitis, which took place in January, 1909, at the Royal Society of Medicine, 89 were males and 88 females. Bacteriology. Ulcerative colitis necessarily includes endemic amoebic dysentery and epidemic bacillary dysentery, or, as it is some- times called, asylum dysentery. The former is a well-marked and distinct endemic form of ulcerative colitis which does not occur in this country, and for further information in reference to it the reader is referred to works on tropical medicine. A great deal of work has recently been done upon the subject of bacillary dysentery, and the organisms which are supposed to cause the disease have been separated. The most important of these are Shiga's Bacillus dysenteries, and Flexner's acid bacillus. They have not, however, fulfilled Koch's postulates, and there is not at present sufficient proof to establish the specific bacteriological origin of ulcerative colitis. Many investigators have maintained that chronic ulcerative colitis and bacillary dysentery are the same disease ; some have even gone so far as to maintain that the cases of chronic ulcerative colitis met with in this country are sporadic cases of amoebic dysentery ; but the latter is certainly not true, except, perhaps, in a few isolated instances, as the amoebae cannot be demonstrated in the stools, nor do the cases bear any but a superficial clinical resemblance to cases of dysentery. Supporting the view of a close relationship between bacillary dysentery and chronic ulcerative colitis. Dr. Carver has pointed out that, both at the Great Northern Hospital in 1902, and at the Westminster Hospital in 1903, an outbreak of acute bacillary dysentery followed the admission into these hospitals of cases of chronic ulcerative colitis. As yet, however, it has certainly not been proved that ulcerative colitis is due to a specific bacterial infection, and it is at present impossible to say whether the organisms discovered in the ulcers are the cause of the ulceration or are a secondary infection. Flexner and Sweet have shown that in cases of bacillary dysentery the lesions in the colon are apparently produced by the elimination of toxins. PLATE IV Fig. A. — Chronic Ulcekative Colitis, with much thickening of the bowel-wall and a granular condition of the mucosa, as seen through the sigmoidoscope. Fig. B. Fig. B. — Appearances in a case of Follicular Colitis. ULCERATIVE COLITIS 157 The toxins are excreted chiefly by the large intestine, and it is the reaction to this process which produces the lesions. Pathology. Many different types of ulceration are seen in the colon, and it is not at present possible to say whether they are different kinds of ulceration, or only different degrees of the same type. In some cases the mucous membrane is so destroyed by ulceration that little normal membrane can be seen anj^vhere in the entire colon, while in others there are only a few isolated ulcers in one or more parts of it. In the majority of cases in which a post-mortem examination has been made, the entire colon was more or less ulcerated. In most of the records I have been able to find, the colon was the only part diseased. Fig. 45.— Ulcerative colitis— sigmoidoscopic except for septic lesions such as abscess, or peritonitis, the secondary consequence of the ulceration. The lesions vary in size, from quite small, punched-out ulcers, the size of a pea, up to large irregular tracts covering many inches. When examined during life with the sigmoidoscope, the edges of the ulcers can be seen to be raised, and to have a bright red areola. The base is generally covered with fine granulations, and there is often either white adherent mucus or a yellow slough adhering to the surface. These sloughs, however, quickly become detached by the constant diarrhoea, and consequently are not commonly found in post-mortem specimens. -Df ULCERATIVE COLITIS The ulcers are most often seen, and appear to commence, in the hollows of the bowel, such as in the depressions between the valvulae conniventes, and in the bases of the saccuH. When the disease is extensive, the ulcers tend to run together, and become confluent, so that they assume a most irregular outUne. Small islands of normal mucosa often remain in places, and stand out like polj-pi above the surrounding ulceration ; similarly, narrow bands or bridges of mucous membrane may be left between the ulcers, and this often gives the bowel a most curious appearance. At first sight it appears as though covered \\dth polypi, but a closer inspection shows these to consist of islands of swollen mucous membrane surrounded by ulceration. In some cases the ulceration has spread almost uniform!}' over the bowel, in others longitudinally, leaving long ridges of normal mucosa standing above the surrounding ulcerated surface. Again, the ulceration may have spread circularh-. Occasionallv the ulcers are all more or less discrete, though numerous, and the appearance is as if the mucosa was honey- combed or trabeculated. Thev are commonly numerous, and extend throughout the greater part, if not the whole, of the colon ; but in a few cases there have been not more than one or two large ulcers. The depth of the lesions varies considerablj- : in some the mucosa appears as if scraped or sandpapered, so that the surface is entirelv removed. This condition is seen in cases examined with the sigmoidoscope, and probabty represents an earlier or milder stage of the disease than is observed in the post- mortem specimens. The surface is raw, bleeding, and has a granular appearance (see Plate IV, Fig. A). Often the greater part of the mucosa is destro^-ed ; in severe cases the muscular coat is exposed in the base of the ulcers, while in some the floor of the ulcer is formed by peritoneum only. In the chronic t\-pe there is usually considerable thickening of the bowel-wall from fibrous tissue. If the ulcers have perforated the muscular coat, there may be some local peritonitis and adherent lymph on the outside of the bowel. The mesenteric glands may be enlarged, and this was noted in several of the recorded cases, though in many there was no glandular enlargement. There is nothing distinctive in the microscopical appearances of ulcerative colitis. Sections of the wall of the colon through ULCERAXn'E COLITIS 159 1 Fig. 46. — Ulcerative colitis, showing the mucous nienibrane entirelj- destroyed down to the muscular coat, except for a few isolated, islands here and there. (From a specimen in Charing Cross Hjspitcii Museum.) i6o ULCERATIVE COLITIS an ulcerated area show the ordinary characters of simple inflammation. In the less severe cases the glands of Lieber- kiihn are seen to have undergone cloudy swelling and to contain fibrinous material in their lumen. The submucosa is usually much thickened, highly vascular, and there is a general round- celled infiltration. The muscular coat is infiltrated with leucocytes, and where the ulceration is deep the fibres are destroyed. The peritoneum is thickened. Where the ulceration has extended through the whole depth of the mucosa, the islets of mucous membrane left between the ulcers can be seen to have become thickened and swollen, with the result that, under the microscope, they present the appearance of polypi covered with mucous membrane. In some instances the ulceration can be seen to have extended under the mucous membrane, leaving it attached by a narrow stalk. The causes of death in the cases which I have been able to collect were as follows : — Cases. Perforation and general peritonitis . . 9 Exhaustion Pyaemia Embolism Anuria 17 4 2 I Perforation is thus a common cause of death. In nearly all, the ulcer which had perforated was in the caecum or sigmoid flexure ; in only one was there a perforation in the transverse colon, and in that a large portion of the transverse colon had sloughed right away. In two cases there was more than one perforation. In one a perforation into the general peritoneal cavity was present in both the caecum and sigmoid flexure, and in the other there was an ulcer in the caecum the size of a shilling opening straight into the peritoneal cavity, and five or six others, also perforating, in the caecum and ascending colon. It is difficult to see how more than one perforation can occur, but it is possible that some sudden strain or distention of the bowel with gas caused several ulcers to give way at the same time. Perforation of an ulcer may occur without causing general peritonitis ; in several of the cases a local abscess or pericohtis had resulted, and was shut off by adliesions from the general peritoneal cavity. In one there was a large abscess in the pelvis communicating by several large perforations with the interior ULCERATIVE COLITIS i6i of the caecum. In another there was a pericoHc abscess in connection with the sigmoid flexure due to an ulcer which had perforated. In one case the bases of some of the ulcers had become adherent to neighbouring coils of small bowel, and perforation had occurred into the small bowel. There was a communication between the ascending colon and the small intestine, and another between the ascending colon and the ileum. Adhesions between different coils of bowel or between the colon and the parietal peritoneum are not uncommon, and once or twice it was found post mortem, on separating the adhesions, that several ulcers had perforated. Although abscess of the liver is a common complication of amoebic dysentery, it is uncommon in other forms of ulcerative colitis, and was only present in two of the cases I have collected. In one of these the abscess was single, in the other there were multiple abscesses. Neither of these patients had ever been out of England, and there was no reason to suppose they had amoebic dysentery. One would expect portal pyaemia to be a common complication, but out of nearly sixty cases it was present in these two only. In one other instance there were symptoms of liver abscess, but the patient recovered without operation. Haemorrhage serious enough to threaten life may result from an ulcer opening up an artery, and in haemorrhagic colitis the bleeding is the most serious symptom. General peritonitis may result from ulcerative colitis without any perforation being present. Symptoms. The main symptom in all cases is diarrhoea ; and it is this which draws attention to the disease. It may begin suddenly, accompanied by severe abdominal pain, or, rarely, may come on insidiously with a slight looseness of the bowels. Usually the patient states that the pain and diarrhoea started quite suddenly, without any very apparent cause. The stools increase in frequency, and blood appears. The ordinary remedies as a rule have no affect upon the diarrhoea, and the patient rapidly loses weight and becomes extremely ill. The number of stools varies considerably. A common number is six to eight, and I have seen several instances where there II i62 ULCERATIVE COLITIS were twentV; in the t\vent3^-four hours. The stools are quite \vater\-, and contain comparativeh" little faecal material, consisting mostly of mucus, blood, pus, water, and undigested food. In a severe case of ulcerative colitis the food passes through the alimentax}- tract with surprising rapiditj-. If charcoal is given with the food, we can easih' ascertain how long any particular feed has taken in traversing the ahmentar\' canal, as the excreta will be coloured black. If this test is apphed, it will be found that a feed wiU sometimes appear in the stools in as short a time as three hours. It is not surprising, therefore, that in bad cases we sometimes see milk in the stools almost in the condition in which it was swallowed. In the worst cases the patient is practicalh- unable to digest an3'thing, and wasting and loss of weight are in consequence rapid and severe. The amount of blood in the stools varies ; in some cases it is considerable, while in- others it is onlv present occasionally in small quantities. It is usually fluid, and intimately mixed with the stool : it ma}^ however, appear as small, jelly-hke clots. The desire to go to stool is sudden and urgent, but defaecation is not as a rule accompanied bj- tenesmus. Personally I have never seen a patient with ulcerative cohtis in whom there was well-marked tenesmus, and although some writers give it as a common s\-mptom, I beHeve it to be exceptional. When present, it points to severe ulceration in the rectum. In acute tropical d3'sentery, however, tenesmus is a common s\-mptom. There is not infrequently considerable abdominal pain and tenderness. The pain is referred to the abdominal wall, but is not weU locaUzed. The tenderness is most marked in the left iliac fossa and in the left loin, but often extends over the whole colon. The character of the stools \'arie5 considerabh-, but they are always thin, water\-, and contain blood. Pus is seldom present in an\- large amount, but can always be detected on microscopical examination. There is always mucus, and often sloughs can be seen if the stools are carefull}' examined. They are usually ver\' foetid. The digestion is much disturbed, and nausea and vomiting ma\- occur and cause considerable distress. Vomiting is, however, exceptional, except in the more acute cases, and, indeed, many patients suffering from chronic ulcerati^'e colitis have surprisingly few sjmiptoms apart from the diarrhoea and consequent loss of weight. I have even seen patients with the ULCERATIVE COLITIS 163 pelvic colon, showing extensive and severe ulceration, who were able to get about and who complained only of the constant diarrhoea. The progress of the disease varies a good deal. Some patients get rapidly worse, go steadily downhill from the first, lose much weight, seem unable to digest anything, and in a few weeks become wasted skeletons. Others seem to go on for months, sometimes a little better, and sometimes worse. Others again, after a severe attack lasting several weeks or months, get better and remain well for a time, only to have renewed attacks which, as a rule, are more severe. The condition usually described is that in which the s\Tnptoms soon become serious, and the patient's life is threatened ; but it is important to recognize that there are other types of chronic ulcerative colitis in which the symptoms are never very severe, and the patient is able to get about, though frequently troubled with diarrhoea. It has been stated that where the symptoms are comparatively mild the condition is not ulcerative colitis ; but frequent examinations with the sigmoidoscope have convinced me that very extensive ulceration may and often does exist, though it seems probable that the ulceration is confined to the pelvic colon. The temperature is commonly, though not invariably, raised. Except in the more severe cases it is not high, but varies between 100'' F. and 101° F. The chart, if examined, usually shows a very irregular temperature of the type we generally associate with chronic septic poisoning. I have seen several cases, however, in which, although there was severe diarrhoea and ihe sigmoidoscope showed extensive ulceration, the temperature never rose over 99° F. while the patient was under observation. These were, however, all very chronic cases, in which the symptoms had existed for months or years. xA-ll observers agree that relapses are very common in those cases which are not fatal. When death occurs it is usually due to exhaustion and wasting ; less frequently to perforation and general peritonitis ; and in a few instances to haemorrhage. At the present day the diagnosis should not be difficult, as the pelvic colon is always involved, and this can be directly examined with the sigmoidoscope. The instrument must, however, be used with great care, because the bowel wall is weak and friable. In experienced hands there is no risk in using the sigmoidoscope ; but no one who is i64 ULCERATIVE COLITIS unaccustomed to the instrument should attempt an examination in suspected ulcerative colitis. {Plate IV, Fig. A.) The disease can, as a rule, be diagnosed from the symptoms ; but unless the sigmoidoscope is employed there are several conditions with which it can easily be confused. The most important of these is cancer of the pelvic colon or upper end of the rectum, which not infrequently gives rise to identical symptoms. Another is a high-lying fibrous stricture with secondary ulceration in the bowel above. The condition may also be confused with enteric fever, and with acute proctitis. Acute tropical amoebic dysentery is not met with in this country, and its sjnnptoms and treatment are so well described in modern works on tropical medicine, that it will not be discussed here. Cases of chronic dysentery are, however, not infrequently seen ; but they differ in no important particular, either as regards symptoms or treatment, from chronic ulcerative colitis, except that when amoebae can be demonstrated in the stools improvement often follows a course of special treatment by ipecacuanha. Natural Healing of Ulcers in the Colon. — It is difficult to find any signs of repair in the specimens of ulcerative colitis beyond some thickening of the bowel-wall and a little adherent lymph on the peritoneum. Occasionally pigmented spots are seen in the colon which have been supposed to be the remains of old ulcers. One would expect that when an ulcer of the colon of any size healed, a considerable scar would be left and there would be a tendency to contraction and stricture. This appears, however, to be very rare. In the formation of scars the mucous lining of the bowel appears to behave very differently from the skin. We know that quite large ulcers in the small intestine due to enteric fever will heal and leave practically no scar, and certainly no stricture or contraction of the bowel-wall. And it is a very striking fact that if the interior of the bowel is examined some year or more after an operation, such, for instance, as an anastomosis, has been performed, the scar is often almost undetectable. I have on several occasions examined the interior of the sigmoid flexure with the sigmoidoscope after a portion has been resected, and been almost unable to find the line of union, so slight was the scar. In a number of cases of ulceration of the colon I have been able with the sigmoidoscope to watch from time to time the ULCERATIVE COLITIS 165 process of repair in ulcers which could be seen in the sigmoid flexure. These ulcers can be seen gradually to diminish in size until only a slight white mark is left, and if examined a little later, even this has disappeared, leaving no perceptible scar. I have seen ulcers as large as a sixpence which looked quite deep, and which apparently exposed or even involved the muscular coat, disappear without leaving any obvious scar. Apparently it is only when the ulceration is very deep, in\'olving the muscular coat, and also very extensive, that any appreciable scar results. I have onh^ twice been able with certaintv to trace a stricture of the colon to a previous ulceration. But though this is very uncommon, there are several specimens in museums of fibrous stricture in the colon, in which it seems almost certain that the stricture is due to ulcerative colitis. It is not uncommon to see a tight fibrous stricture occur in the rectum as the result of extensive ulceration, and the same thing doubtless occasionally occurs in the colon. It seems probable that most cases of ulcerative colitis in which the ulceration is sufficiently severe to cause contraction, die from the initial disease. On one occasion I examined with the sigmoidoscope a woman who gave a history of previous bowel trouble which suggested ulcera- tion in the pelvic colon, and I was able to see a narrow ring stricture in the middle of the sigmoid flexure, evidently of a fibrous nature, and which appeared probablv to have resulted from the contraction of a healed ulcer. A case is reported by Dr. Tooth, of a woman who died from chronic ulcerative colitis in St. Bartholomew' 's Hospital ; the colon was extensively ulcerated, and there was a contraction of the bowel at the splenic flexure. Ouenu records a death from intestinal obstruction due to a simple ulcer at the lower end of the sigmoid, which had con- tracted and caused a stricture. Prognosis. The prognosis is distinctly bad unless an operation is per- formed. A majorit}' of the cases die, and the mortality is very high. The more extensive use of the sigmoidoscope, however, has proved that many recover, and that the condition is not so fatal as was previously supposed when a post-mortem examination was the onlv certain means of dia.mosis. i66 ULCERATIVE COLITIS With non-operative treatment, recovery, even if it occurs,, is very slow, and recurrence in a few months extremely common. In the more acute cases, the prognosis is so grave that no time should be wasted in a prehminary trial of non-operative measures, but operation should be performed at once before the patient has become seriously weakened by the disease. Out of 80 cases which were admitted to St. Thomas's Hospital between the years 1883 and 1907, 50 per cent died, and the condition of the remainder was as follows : — No improvement . . . . . . 14 Improved, but symptoms persisting . . . . 19 Cure or great improvement . . . . 7 Thus onty 7 cases out of 80 showed any marked improvement as the result of treatment, and of these 7, 5 were apparentlj'- treated by operation. Follicular Ulceration. — This is generally considered a distinct form of ulcerative colitis. The ulcers are small and discrete. They start by swelling and inflammation of the solitary follicles of the mucosa ; the central portion then sloughs and leaves a small crater-like ulcer wdth a bright red areola. The ulcers do not extend deeply ; they are circular in outline, with well-marked edges. They are always multiple. They maj'- enlarge to about the size of a pea, but are seldom larger than this, and are never confluent ; but it is by no means certain that the more extensive ulcers do not sometimes originate in follicular ulceration. I have not found any case in which this form of ulceration has caused perforation. (See Plate IV, Fig. B.) This form of ulcerative coHtis occurs as a complication of other diseases. It is chiefly of interest here because it occurs in association with cancer of the alimentary canal. I have found it so associated in three cases. In one there was cancer of the stomach and follicular ulceration of the whole colon. In one there were numerous follicular ulcers helow a cancerous stricture of the sigmoid ; and in the third case there was epithelioma of the anus. Symptoms and Prognosis. — The S3^mptoms are the same as in other forms of chronic ulcerative colitis, but are much less severe when the condition occurs in adults. It is a not uncommon form of acute colitis in children, and manv of the summer ULCERATIVE COLITIS 167 diarrhoeas which yearly account for so ^ much of the infant mortaht): in the east end of London are of this nature. Haemorrhagic Colitis. — I have included this condition in the chapter on ulcerative colitis because it most conveniently comes under that heading, though strictly speaking there is not always any definite ulceration. It is a very rare form of colitis, and at present very little is known about it. It is an extremely serious and often fatal disease, and there are not sufficient cases at present available to enable us to draw any reliable conclusions as to its etiology. It appears to be a form of so-called bacillary dysentery, as everything points to a microbic infection as the cause. It occurs in young adults, and arises suddenly without any apparent cause. The character- istic symptoms are profuse and continuous haemorrhage from the bowel, and uncontrollable diarrhoea. It closely resembles ulcerative colitis and, like that disease, often starts suddenly with abdominal pain. There is profuse diarrhoea, and I have seen cases in which there were as many as twenty-five stools in the twenty- four hours. The amount of blood lost in the twenty-four hours ma}^ be very considerable, with the result that the patient rapidly becomes dangerously anaemic. All food passes almost straight through the intestine without being digested, and in a very short time the patient is reduced to an extreme condition of emaciation. The pulse is rapid and almost imperceptible, the temperature is raised, and the condition of the patient resembles that seen in a severe attack of typhoid fever during the third week of that illness. In one of my cases there was hjrperpyrexia, the temperature going up to 109° F. on one occasion. The stools are liquid and extremely foul smelling. The blood is intimately mixed with them, and is present in such quantities that they are bright red in colour, often appearing to consist of little else but blood. Diagnosis and Symptoms. — The diagnosis can only be made with certainty by means of the sigmoidoscope. The appearance of the mucous membrane is characteristic, the whole surface being dark red and having a spongy appearance. Blood can be usually seen oozing from it everywhere. Definite ulcers may or may not be present, and this will depend to some extent on what is the stage of the disease at the time of examination. i68 ULCERATIVE COLITIS The condition somewhat closely resembles enteric fever in S5^mptomatolog3^ and without a sigmoidoscopic examination might be mistaken for it. XMdal's reaction is, however, not obtainable, and there are no spots ; moreover, haemorrhage is present from the beginning. I have no doubt, howe^'er, that many cases hsive been mistaken for tjrphoid fever. The inflammation is not confined to the mucous membrane, but involves all the bowel-coats, and the peritoneum covering the bowel shows commencing peritonitis. The following is a good instance of this rare condition : — The patient was a lady, aged 30. She was suddenh' seized with severe abdominal pain, followed by diarrhoea. The stools contained blood and were very offensive. She continued to get about, but the diarrhoea increased, and at the end of a week she was having as many as fourteen stools daily, all of which contained blood. There was no further pain or other s;ymptom except progressive weakness and emaciation. She came up to London and saw her doctor, who immediately sent her to bed and put her on a light diet. The bleeding, however, continued in spite of treatment, and she had a temperature ranging between 101° and 102°. I was asked to see her on the fifteenth daj^ after the onset, and a sigmoidoscopic examination showed the mucosa of the pelvic colon to be spongj', bleeding, and of a dark-red colour. Hemorrhagic colitis was diagnosed, and it was decided to perform appendicostomy in the hope of controlling the bleeding, which was already most serious. The operation was performed at once, and a large quantity of very foul material was washed out of the colon. The next day the patient's temperature, which had come down as the result of the operation, went up within an hour and a half to 109°, and was onl}' got down again b}^ continuous sponging and the application of ice, iced water being also run into the colon. For the next two days there were repeated attacks of hj-'per- pyrexia, and on two occasions the temperature reached 107° before it could be checked. The bleeding from the colon was stopped in twent3^-four houi-s as the result of frequent irrigation of the colon with water and i per cent arg^-rol. A specimen of the stools, which was examined bacteriologically, showed large numbers of pneumococci, which were also successfully cultivated, and the condition appeared to have been due to a primar}.' infection of the colon b^- this organism. There were ULCERATIVE COLITIS 169 no symptoms of lung tz-ouble. At the operation the caecum, which was the only part of the large bowel examined, was found to be acutely inflamed, the wall was considerably thickened, and there was much adherent lymph on the peritoneal surface. As a result of frequent irrigation the colitis got better, and the stools became almost normal in appearance and free from blood. The temperature came down, and the patient seemed to be well on the way to recovery, when she died suddenly from heart failure.* Treatment. — The best treatment in these cases, in fact the only treatment which seems to control the haemorrhage, is to perform appendicostomy and keep the colon washed out. This rapidly controls the bleeding and at the same time w^ashes away the highly toxic material in the colon, which, owing to the damaged condition of the bowel w^all, is being absorbed and poisoning the patient. The condition is a very serious one, both on account of the great loss of blood and also the severe degree of toxaemia which results from it, and I am personally convinced that no time should be wasted in trying palliative measures, but appendicostomy should be performed as soon as possible after the condition has been diagnosed. The bowel should be washed out at once, and the washing continued until the fluid coming from the tube in the rectum is quite clean. After that, the colon should be irrigated every three or four hours until the hemorrhage is controlled. Hazeline, in the proportion of two drachms to the pint, may be added to the water used for irrigation, and if this fails to stop the bleeding, the bowel may be washed through with i per cent argyrol. During convalescence the feeding wall require the most careful management, and, in fact, these cases call for everj^ resource of modern medical knov/ledge and skill if they are to be con- ducted to a successful issue. Distention or Stercoral Ulcers. — These are commonly found above a stricture of the colon or rectum. The most common situation is in the dilated portion of bowel immediately above the stricture ; but they may occur in any part of the colon above the stricture ; thus the stricture may be in the rectum, and the ulcer in the caecum. They are usually multiple, * Proc. Roy. Soc. Med., vol. iii., No. 2, Clin. Se^t., p. 48. 170 ULCERATIVE COLITIS discrete ulcers with well-marked edges. They do not differ in any important particular as regards their morbid appearance from the form of ulceration already described. They apparently arise as the result of the local irritation and inflammation caused by retained faecal material above the stricture. In fact, they may be said to be traumatic in origin. They are seen in cases of faecal impaction when there is no stricture, and may occur as the result of chronic constipation alone. I have seen one such case in which several stercoral ulcers were present in the sigmoid flexure (see Fig. 44) of an old woman who for years had suffered from chronic constipation. They are for the most part quite shallow, and involve only the mucous membrane ; but when they occur above a stricture they may in time expose the peritoneum, and perforate or give rise to local abscess formation. Simple Perforating Ulcer of the Colon. — There are a few rare cases in which a patient has developed acute general peritonitis, and either at the time of operation or post mortem a single simple ulcer in the colon has been discovered which had perforated into the peritoneal cavity. These cases do not appear to belong to the same class as those of ulcerative colitis which have previously been described, and I have therefore placed them separately, though it may subsequently transpire that they should not be so divided. They bear a close resemblance to perforating duodenal and gastric ulcers. They are distinguished from ordinary ulcerative colitis in that there is only a single ulcer, or at most two, the remainder of the colon being healthy, and that there are none of the usual sjnnptoms of ulcerative colitis ; in fact, in many there do not appear to have been any definite symptoms until the sudden onset of general peritonitis. In one case the patient, a man who was not known to have suffered from any bowel trouble, was operated upon for a stone in the bladder ; he died three days after the operation, and post mortem there was found general peritonitis due to a simple, ulcer in the splenic angle of the colon which had perforated. In a case of Ouenu's, the patient, who was suffering from acute pneumonia, developed acute abdominal pain on the fourteenth day of the illness, and died with symptoms of general peritonitis. Post mortem there was a single ulcer in ULCERATIVE COLITIS 171 the descending colon which had perforated, and also an ulcer in the stomach. In several there was a stricture or obstruction in the colon below the situation of the ulcer. In one, a volvulus of the sigmoid flexure had been operated upon and untwisted three da3.'s before an ulcer in the caecum perforated. In another case reported by Ouenu, the patient died after an illness lasting seventeen days, with symptoms of perforation and peritonitis. Post mortem there was a single ulcer about one inch in diameter in the transverse colon, which had per- forated ; there was also an ulcer in the stomach. In one case there was a simple ulcer the size of a shilling in the sigmoid flexure, which had perforated and caused an abscess ; the patient died from pyemia. I have been able to find records of eighteen such cases in which there was either a single ulcer in the colon, or two small ulcers close together, the remainder of the colon being quite free from ulceration. All but two were men, and their ages varied between 27 and 67. The situation of the ulcer is shown in the following table : — Sigmoid flexure Ascending colon or hepatic flexure Descending colon or splenic flexure Transverse colon Csecum Cases 7 4 5 I 2 In three cases an obstruction existed below the ulcer. In one the ulcer w^as tuberculous, and one was due to typhoid fever. One patient was suffering from acute pneumonia ; but there is not positive evidence that the ulcer was caused by the pneumococcus. In the remaining cases there was present no apparent cause for the ulcer, and no other lesion of the colon. In most there was a history of constipation, but otherwise no trace of any bowel trouble until the sudden onset of symptoms of perforation. In one or two there was a history of localized pain and tenderness in the abdomen over the situation of the ulcer for a few weeks. In one case two small concretions were found outside the bowel which had evidenth^ come through the perforation. The ulcer had perforated the bowel wall in all but one of the cases, and had caused either an abscess or general peritonitis. In a case reported by Dr. Bradbury, there was no apparent 172 ULCERATIVE COLITIS perforation. The patient was a man, aged 30, who died after an illness which commenced with sudden pain in the abdomen. Post mortem there was a single small ulcer of the caecum, which had not perforated. The appendix and the rest of the colon and small bowel were quite health}^ There were multiple abscesses of the liver and a right-sided empyema. In tw^o of the cases there was an ulcer in the stomach in addition to that in the colon. This is particularly interesting in view of the close resemblance which these ulcers of the colon bear to gastric ulcers. In three the lesion was undoubtedly a distention or stercoral ulcer occurring abo\'e a stricture or obstruction, and it seems possible that in many of the others the ulcer was of a traumatic nature, and caused b}-^ the retention for long periods of hardened faecal masses. In addition to the forms of perforating ulcer of the colon already mentioned, there are two others of importance. Typhoid ulcer aiion of the colon is not common, but I have been able to collect seven cases in which a typhoid ulcer of the colon per- forated and caused fatal peritonitis. In one case the ulcer was in the ascending colon, in two in the hepatic flexure, in two in the caecum, and in two in the sigmoid flexure. Tuberculous ulceration of the colon ma\' also result in perforation. Treatment of Ulcerative Colitis. Chronic ulcerative colitis is a disease about which, until quite recently, but little was known, and about which there is still much to learn. The cases have either had no special treat- ment or have been treated b}^ restricted and special dietary, combined with attempts to wash out the lower bowel with antiseptic or silver solutions. The cases treated by careful nursing and dietar3/-, or by the administration of drugs, almost invariabh' died, and the only medical — as opposed to surgical — treatment which has been at all successful has been that in which an attempt has been made to wash out the bowel with weak solutions of antiseptics ; though it cannot be said that even this has met with much success. Dr. Hale White, in the discussion which took place at the Ro3'al Society of Medicine on ulcerative colitis, stated that he knew of three cases which had apparently recovered as the result of treatment by coli vaccine. Apparently the first instance of chronic ulcerative colitis ULCERATIVE COLITIS 173 treated by operation was a case of Hahn's, in 1880. The patient was a prostitute, and it was at first supposed that the ulceration was due to syphihs, but as it did not improve under antisyphiHtic treatment, he performed colotomy. Previous to operation she was very ill, and had lost 68 lbs. in weight, but she made a complete recovery. As the result of an attempt to close the artificial anus two years later, she died of pyaemia. The first successful caecostomy for ulcerative colitis seems to have been performed in Italy, in 1887, by Novara. Of the 60 cases which I have been able to collect, 33 were treated medically and 27 by operation. Of the cases not operated upon, 26 died and only seven recovered, while of those operated upon, 21 recovered, and only six died. Died. RECOVEKBO. j ™--- Cases not operated upon . . 33 Cases operated upon 27 26 6 7 21 78 22 Total 60 32 28 These figures are striking enough, but we have also to take into consideration the fact that operation has hitherto been reserved as a rule for the worst cases, and often after other forms of treatment have failed. There is thus every reason to hope that when the value of operation is better known, the great majority of the patients will recover, and instead of recovery being the exception, it will become the rule. There are two methods of treatment by operation : — (i) Giving rest to the colon by establishing an artificial amis ; (2) Making an opening through which the colon can be irrigated and the u cerated areas kept clean, Two other methods suggest themselves, namely, to short- circuit the colon by ileo-sigmoidostomy, and to excise the diseased colon. Neither of these is, however, possible except in most exceptional cases. The rectum and sigmoid are generally the parts of the bowel in which there is most ulceration, and therefore the anastomosis would have to be done with diseased bowel. For the same reason excision would not be possible 174 ULCERATIVE COLITIS even if the patients were not too ill to stand so severe an operation. 1. Giving Rest to the Colon. — As the pathology of ulcerative colitis clearly shows that the ulceration usually extends through- out the whole of the colon, it is obvious that the artificial anus should be made in the csecum if the operation is to be successful. This is also clearly shown by the results of operation, as out of six cases treated by colostomy on the left side, three died, while the six cases treated by csecostomy all recovered. Where right-sided colostomy or csecostomy has been performed, the results have been good as regards a cure of the ulceration. The symptoms ha\'e subsided, and the patient has rapidly improved in health. The operation is, however, objectionable, as a right-sided colostomy is even more unpleasant than a left- sided colostomy. Moreover, it is frequently impossible or inad- visable to close the opening, and it has to be retained as a permanent outlet for the fseces. In several cases an attempt to close the opening has immediately resulted in a recurrence of the symptoms of ulceration, and in a few, fatal peritonitis has resulted from the attempt. Mr. Makins,* who has performed the operation in six cases, has given it as his opinion that if the opening cannot be closed in eight or nine months, it will sub- sequently become impossible to close it on account of the contraction which occurs in the disused colon, and that if a right-sided colostomy is performed in these cases the patient must be prepared for the probability that the opening will be a permanent one. Therefore, as regards curing the patient, a right-sided colostomy may be expected to give good results ; but it will not infrequently be at the expense of leaving the patient with a permanent artificial anus. A right-sided lumbar colostomy is preferable to a csecostomy on account of the more solid nature of the stools, and appears to give as good results as a csecostomy. 2. Operation for Establishing a Means of Irrigating THE Colon. — The operation of choice in cases of ulcerative colitis is, without doubt, appendicostomy, or if this is impossible owing to the appendix being diseased or having already been removed, a valvular opening which will just admit a catheter should be established. At first the colon should be washed out twice * Proc. Roy. Soc. of Med. Jan. 26, 1909, Med. Sect. ULCERATIVE COLITIS 175 daily with either plain water or normal saline, a tube being placed through the anal sphincters to allow the fluid to run out. Later, a weak solution of protargol or arg^Tol may be used with advantage. This operation gives excellent results ; the ulceration, as a rule, quickly heals, the patient puts on weight, and the diarrhcea is controlled. I have seen most excellent results from this operation in bad ulcerative cohtis, and it has such manifest advantages over colostomv that I think it should always be done except, per- haps, in a few exceptional cases. It does not leave the patient with an unpleasant opening, or cause him the least discomfort or inconvenience, and it can be closed at any time without an operation. The following are instances of the good results which follow this operation : — Case. — The patient was a man, aged 35, who for nine months had been suffering from almost constant diarrhoea. He was very weak and much wasted. The stools contained a considerable quantity of blood. A sigmoidoscopic examination showed numerous discrete ulcers in the pelvic colon. Appendicostomy was performed, and the colon kept washed out with warm water. The diarrhoea was at once controlled, there was no further bleeding, and the patient made a rapid recovery. A month after the operation he left the hospital. He continued for six months to wash the colon out daily, but returned to his employment. He had no further sym- ptoms, and a sigmoidoscopic examination six weeks after operation showed that all the ulcers were healed. A year and three months after operation he was quite well and had had no recurrence of the previous symptoms. Case. — A lady, aged 25, had for five weeks been suffering from constant diarrhoea, and the symptoms, in spite of all treatment, had been getting worse during the last month. The stools contained large quantities of blood, she had become very anaemic, and wasted almost to a skeleton. Some six months previously she had had a slight similar attack, which had, however, quickly passed off. On the present occasion, however, she had become steadily worse, and her condition was very grave. The sigmoidoscope showed extensive ulceration and a hsemorrhagic condition of the mucous membrane. Treatment by a special vaccine failed to do any good. Appen- dicostomy was performed, and the colon was washed out frequently with warm water. As a result of this treatment the haemorrhage 176 ULCERATIVE COLITIS and diarrhoea were controlled within thirty-six hours. The patient rapidly improved in health, and in two months was quite well. The irrigation was continued once daily for the next two months. Case,. — I was consulted by a lady, aged 31, who three years ago had contracted dysentery while resident in the East. She had suffered on and ofE ever since from diarrhoea and bleeding from the bowel. When I saw her the bowels acted six or seven times a day, there was blood in the stools, and she was often sick. Medical treatment had quite failed to do any good, and she was practically confined to bed, the least attempt to move about bringing on severe diarrhoea. Appendicostomy was performed, and at the operation a number of chronic ulcers could be felt in the colon, especially in the transverse portion. The bowel was kept washed out, and in three weeks all the symptoms had disappeared. She became quite well, and was able to return to' the East. I have since heard from her, and there has been no return of the symptoms. Of the 18 cases which I have been able to collect in which appendicostomy was performed, 17 recovered, and 8 of these remained well and free from any relapse. One died a year later from the results of another operation, though there was no return of the ulceration. One died three weeks after the operation, but it was found post mortem that the lower part of the ileum was ulcerated in addition to the colon. Appendicostomy and irrigation of the colon appears to be the best treatment in these cases. It should be performed as soon as possible, and not as a last resort. Treatment of Complications. Of these there are three which are likely to call for surgical treatment : (i) Perforation ; (2) Hcsmorrhage ; (3) Abscess. I. Perforation. — ^With very few exceptions this complication is fatal, unless an operation can be performed in time ; and only immediate intervention can save the patient's life. The success which has attended the treatment by operation of perforated gastric ulcer, and perforation of the appendix, can certainly be repeated in dealing with these cases of per- forating ulcer of the colon, once the condition becomes suffi- ciently well recognized for an early diagnosis to be made, and providing the surgeon is able to operate soon after the per- foration has taken place. Unfortunately, up to the present, this has seldom been the case ; the perforation has either not ULCERATIVE COLITIS 177 been diagnosed during life, or the surgeon has been called in too late for there to be any reasonable chance of doing good. A correct diagnosis is very difficult in these cases, and it will seldom be possible for the clinician to do more than diagnose a probable perforation in some part of the intestine. Unless the surgeon bears in mind the possibiUty of a perforating ulcer of the colon when he comes to operate, and carefully examines the colon after having excluded a perforated appendix or gastric ulcer, the perforation will probably be missed. This occurred in one case where perforation and general peritonitis were diagnosed and the abdomen opened ; a slightly inflamed appendix was removed, but the cause of the peritonitis, which was a perforation of the colon at the hepatic flexure, was missed, and the patient died. The difficulty of finding and closing the perforation may be considerable ; it may be in any portion of the colon and on any aspect. Moreover, there may be more than one perforation in the same case. The method of dealing with the perforation will vary with the nature of the case. It may be treated like a perforation of the stomach and closed by a purse-string suture reinforced by a row of Lembert sutures. In one case, a Paul's tube was tied into the perforation, which was in the caecum, and an artificial anus established. The operation in this case was performed too late, and the patient died. Though this is a rapid method of dealing with the perforation in cases when speed is of the first importance, it is not a satisfactory operation. Another method is to resect the ulcer and close the wound in the bowel in the opposite direction, so as not to narrow the lumen ; or, if the ulcer is large, to resect a few inches of the colon and unite the ends. I have been able to collect 42 cases of perforation of the colon due to simple ulceration. This does not include any cases of perforating false diverticula. All died, with the exception of three. Only six were operated upon, but of these, three recovered. Thus, without operation the mortality would appear to be 100 per cent, and there is no doubt that this mortality can be greatly reduced by operation. Of the six cases operated upon, the ulcer was missed in the three that died. One was treated by closing the perforation, and recovered. In one, an abscess was opened and a faecal fistula found ; later, the portion of colon (sigmoid flexure) containing the ulcer was successfully resected. 12 178 ULCERATIVE COLITIS In the third case that recovered, the operation consisted only of opening an abscess. In another, enterotomy was performed, but the patient died, and post mortem a perforating ulcer in the sigmoid was discovered. 2. HAEMORRHAGE. — This is best treated by washing out the bowel with some suitable astringent such as hazehne two drachms to the pint, complete rest, and the administration of opium (see page 167). 3. Abscess. — As soon as there is reason to believe that an abscess has formed, an operation should be performed and adequate drainage provided for. REFERENCES. Hale White. — Guy's Hasp. Rep. 1888. NoTHNAGEL. — Diseases of Intestines and Peritoneum. English edition edited by H. D. Rolleston. Dickinson. — Trans. Path. Soc. xxxii. " Discussion on Ulcerative Colitis," Proc. Roy. Soc. of Med. Jan. 26, 1909. 79 Chapter XIII. PERICOLITIS. By this is meant a condition of inflammation around the colon, and involving its walls. In many respects it closely resembles perityphHtis or appendicitis, generally differing only in the locality in which it is situated. It is only of comparatively recent years that pericolitis has been recognized as a definite form of disease, though many observers had previously recorded cases of abscess or inflam- matory tumours in connection with the colon. In looking up> old records one not infrequently meets with cases which were obviously of this nature, but, as with appendicitis before it became a well-recognized condition, little attention was paid! to them, and in very few instances were really careful obser- vations made. They were classed as inflammation of the bowels, post-peritoneal or intra-peritoneal abscess, general peritonitis, etc., without any distinction being made as to the causation or pathology. Isolated specimens are to be found in museums, but in many instances they are wrongly described or classified, and in not a few the specimen is labelled " Cancer of the colon." Lately more attention has been paid to this disease, and several carefully observed cases have been recorded. Even at the present time, however, pericolitis does not find a place in the ordinary medical text-books, and many medical men know nothing about it, or look upon it only as a rare pathological condition of little interest except to the pathologist. Pericolitis is probably not a rare condition, but on the other hand it is one which occurs comparatively often, and I believe that, when its S3nnptoms and pathology are well known and recognized, it will be found to be a by no means uncommon disease of the alimentary tract. Post-mortem statistics would lead us to conclude that peri- colitis is a rare disease. Cases are very difficult to find in the i8o PERICOLITIS post-mortem records of large hospitals, and the same applies to the hospital case-books. If classified at all, it is under the general head of abscess, and usuallj^ the cause is not even suggested. The great majority of cases have ended fatally, and the condition has only been detected post mortem. Etiology. Pericolitis is a disease of advanced life. The majority of the patients are oxev the age of forty, the a\'erage of the cases I have been able to collect being fifty years. The youngest I have found is that of a girl of eighteen. There are two others of twenty-two and one of twenty-three in mv series, but most are considerably older. It is somewhat remarkable that, apart from tubercle, there appear to be no records of the condition in children, although intestinal complaints are common enough in infancy. The reason why the disease . is chiefl\' confined to the later part of life lies probabl}^ in the important part played by chronic constipation as an etiological factor. The portion of the colon most commonly attacked in peri- colitis is the sigmoid flexure, but an}' part may be affected. In the great majorit}' of cases the condition occurs either in the sigmoid flexure or lower part of the descending colon. In a few the splenic angle has been the site of the disease, and I ha\'e been able to find two instances onl}- of the transverse colon being affected. Pericolitis, like all forms of inflammation, may be either acute or chronic, but except in relation to the symptoms, such a classification is of little if an}- value, and the cases will therefore be arranged on a pathological basis. The term is a wide one and covers a number of pathological conditions, or rather there are many such conditions which may give rise to pericolitis. Many cases have been described as pericolitis sinistra, peri- sigmoiditis, and diverticulitis ; but there is no advantage in using these names : the term pericolitis includes them, and the condition does not differ in any important particular when it occurs in different parts of the colon. Under the general heading we should include most of the cases of tuberculosis of the colon, and certainly all those of hyperplastic tuberculosis. Most cases of cancer of the colon PERICOLITIS iSi are also sooner or later complicated by a pericolitis, and it is necessary, therefore, to include this form of the condition. As, however, the subjects of tuberculosis of the colon and of cancer are more conveniently considered elsewhere, these two conditions will not be included here. It is obvious that with the exception of those cases in which septic infection has spread to the bowel wall from some source unconnected with the colon, there must be a lesion of the wall of the colon which allows infecti\"e material to escape from the bowel lumen. In other words, there must be either a perforation of the colon or an infiltra- tion of its wall by some infective process before pericohtis can occur. In the order of their importance in producing pericolitis, the causes are as follows : (i) Diverticula of the colon ; (2) Ulceration ; (3) Perforation by foreign bodies ; (4) Tubercle ; (5) Cancer ; (6) Svphilis ; (7) Traumatism. I. Diverticula of the Colon. — Bv far the most important cause of pericolitis is the formation of acquired diverticula. Since attention was first attracted to the presence of these diverticula they have been a source of much interest to surgeons and pathologists, and it is now becoming evident that the}^ are by no means as rare as was at first supposed. They consist of small pouches or hernial protrusions of the colon, somewhat resembling the pouches seen in the bladders of old men who have had obstructive urinary trouble. They vary in size, from minute canals which can hardly be detected except by microscopic examination of cut sections of the bowel, to large elongated pouches resembling the vermiform appendix or a Meckel's diverticulum. They are sometimes round, and may be described as resembling cherries, but more often are long finger-like pouches with a somewhat dilated extremity. In one of my cases the largest diverticulum was about 2^ inches in length, and about the thickness of a normal appendix vermiformis. It passed down between the layers of the mesosigmoid, and the opening from the bowel, which was at the mesenteric attachment of the sigmoid, easily admitted a large-sized probe. In many cases, however, they are much shorter than this, and will admit only a bristle with difficulty. The commonest situation for diverticula is near the mesenteric attachment of the bowel ; but they may occur at any position between the longitudinal muscle-bands. They may be found l83 PERICOLITIS on the free edge of the bowel almost opposite the mesenteric attachment. It is not uncommon to find one of them passing into an appendix epiploica, and several writers have concluded that these diverticula are simply hollow appendices epiploicae which communicate with the bowel lumen. This is certainly not the case, as the normal appendices epiploicae are simply small accumulations of the sub-peritoneal fat or sub-peritoneal Fig, 47. — Drawing of the pelvic colon in a man, aged 62, showing numerous diverticula. One large diverticulum passed down between the layers of the mesosigmoid ; its e.\tremitj' was dilated and contained a stercolith. hpomata, and have no connection whatever with the muscular coat of the bowel, and certainly not with the mucous membrane. The diverticula on the other hand, are direct protrusions from the bowel lumen, and the fact that they may sometimes be found passing into an appendix epiploica must, I think, be looked upon as merely a fortuitous circumstance. They occur at just the positions where the appendices are PERICOLITIS 183 commonly found, and it is probable that in seeking a line of least resistance in which to extend their growth they readily find their way into the appendices. In point of fact they are frequently found to lead into the appendices, and they then become distended into a bulbous end which remains connected to the bowel lumen by a narrow channel. Not infrequently they push down between the layers of the mesosigmoid, and may then reach a considerable length. In Charing Cross Hospital Museum there is a beautiful specimen of a colon showing these diverticula occupying the cippendices epiploic^. The}" open into the bowel lumen between the \'alvute conniventes by openings which, in most cases, will admit the tip of the little finger. The ends of the diverti- cula are dilated into pouches occupying the appendices epiploicae. Most of the fat previously present in the appendices has been absorbed, but in some of them a thin layer of fat still remains separating the diverticulum from the peritoneal covering. In this specimen there appears to be very little thickening or inflammation around the colon. These diverticula are true protrusions of the bowel ; and at first, and before secondary changes have occurred in them, all the coats of the colon are represented in their walls, except occasionally the muscular coat. Presumably, when the muscular coat is not represented, the pouching has occurred between the fasicuH of the muscle, and thus has not carried the muscular coat with it. In a considerable number, however, the muscular coat can be demonstrated in the wall of the diverticulum. As it enlarges, and as secondarv inflammatory changes occur in its walls, any muscular tissue atrophies, so that, in the later stages, no trace of any muscular tissue can be detected. Edel has demonstrated the presence of a muscular coat to be quite frequent on microscopical examination, and this was also shown in one of Mo\Tiihan's cases. In one of my own cases the remains of the muscular coat could be clearly seen on microscopical examination. The diverticula are always lined by mucous membrane, though this may be much changed from secondary inflam- mation. There is usualh' a thick layer of fibrous tissue in their walls, due mostly to inflammation. Outside they are covered by peritoneum, and if they have passed into an appendix, there mav be a laver of fat. -i84 PERICOLITIS They would appear from post-mortem statistics to be very rare, out of 12,115 necropsies collected from three hospitals, diverticula of the colon were only present in 28. But it is highly probable that they are nothing like so rare as these figures seem to show. I have been able to find 58 cases. Graser, who examined microscopically the sigmoid flexures from 28 bodies of elderly persons, found small diverticula in 10. They may be either congenital or acquired, but are certainly an acquired condition in the vast majority of cases. This is shown by the fact that pericolitis due to diverticula apparently does not occur in childhood, but on the other hand is chiefly confined to elderly people. I have been entirely unable to find a single instance by examining the colons of children and infants. Fig. 48. — Diagram of a diverticulum of the colon. _ (A) Interior of colon. (B) Cavity of diverticulum. (C) Stercolith. (D) Appendix epiploica. (E) iMuscnlar coat of colon. Diverticula are not peculiar to the colon, but may occur in the small intestine, apart from Meckel's diverticulum. They are not found in the caecum, and but rarely in the ascending and transverse colon. The commonest situation is in the lower part of the descending colon, and more especiall}^ in the sigmoid flexure. They never occur in the rectum, probably because of the thicker muscular coat of the latter viscus. They may be single, but in most cases are multiple. In man}- of the cases great numbers of these diverticula are present. It is interesting to notice that in a case recorded by Rolleston there was a pressure diverticulum of the pharynx in addition to diverticula in the sigmoid flexure. Acquired diverticula of PERICOLITIS 185 the colon generally contain fecal material : in fact one might say that they invariably do ; and it is to their contents rather than to themselves that the}/ owe their pathological significance. In many cases the fecal material has become hardened from long residence within the pouch, and has formed a concretion or stercolith. In one of my cases the concretion was of the size and consistence of a date-stone. They are generally found in the pouched extremity of the diverticulum. The cause of the formation of these diverticula has been the subject of considerable discussion ; but there is little doubt they are simply pressure herniae of the mucous membrane, produced in most cases by old-standing constipation. The youngest case in which they have been found is Fielder's, of a patient aged 22. In most the subjects are elderly. In 80 cases collected by Telling, the average age was 60, and in my series, is about the same. This, and the fact already referred to, that post mortem they are not found in children, but only in adults, and chiefly in elderly adults, point to some long-continued cause, associated probably with weakening of the musculature of the gut-wall from atrophy. The fact that chronic constipation is present in most of the cases in which diverticula are found, combined with the other fact that they are commonest in the sigmoid flexure, which we know to be the chief receptacle for faecal material, and certainly that portion of the bowel in which the contents are longest retained, seems to support the view that constipation is an important etiological factor. But it must not be forgotten that constipation is very common without the formation of diverticula. Also, if constipation were the only cause, we should expect to find diverticula more frequently present in women than men ; but the reverse is apparently the case. While, therefore, it cannot be doubted that constipation is an important factor, there must be some other cause to account for their formation. A fact of some importance, first noticed by Klebs, is that the commonest situation for the diverticula is along the edge of the mesenteric attachment, which is also the position at which the blood-vessels of the gut pierce the muscular coat. These are obviously points of weakness in the bowel wall, but on the other hand many of the diverticula occur on the convexity of the bowel, where there are no vessels entering. i86 t'ERIGOLITIS I think the probable explanation of the formation of these pouches is that they are true pressure-herniae through a weakened muscular wall produced by chronic constipation. They are a kind of exaggeration of the normal sacculi of the colon occurring between the longitudinal muscle-bands. That pressure is not the sole cause is evident from the fact that they are not commonly found above a stricture of the rectum, as one would otherwise expect. I have seen one case in which a large diverticulum was present in the upper part of the sigmoid above a rectal stricture Fig. 49. — Section of the wall of the colon in a case of pericolitis due to multiple diverticula. (carcinoma) ; but although I have collected a large number of cases of these diverticula, I have found no other such instance. Pathological Changes in Acquired Diverticula of the Colon which may cause Pericolitis. — The pathological conditions which may occur in one of these diverticula are practically identical with those which may occur in the vermiform appendix. Once formed, the pouch tends to enlarge and to elongate beneath the peritoneum. Faecal material will find its way into it, but will not readily get out again, with the result that a concretion is soon formed. The muscular coat, if present, soon PERICOLITIS 187 atrophies and the mucous membrane becomes thinned or ulcerated, so that in their later stages the pouches have very thin walls consisting of little more than peritoneum. As with the appendix, the presence of the feecal concretion readily sets up ulceration in the interior of the diverticulum, and we thus have inflammation of the wall of the diverticulum, and all the factors necessary for the production of an abscess or perforation. Perforation may result either from sloughing of the concretion through the walls of the diverticulum (and in one or two cases the concretion has been found loose in the peritoneal cavity), from gangrene of the diverticulum, or from the formation of a local abscess which has subsequently burst into the peritoneal cavit\\ Examples of all these conditions are to be met with. Fig. 50. — Tuberculous pericolitis producing a stricture. The stricture is ulcerated, and the colon above dilated. Occasionally a chronic pericolitis is set up which results in the formation of a dense mass of fibrous tissue around the ■diverticula, protecting them from perforating, but causing a dense cicatricial mass which may result in obstruction of the bowel, and w^hich may closely simulate malignant disease. Apart from the presence of concretions, diverticula may contain foreign bodies, and two cases are recorded by Bland Sutton •of an inflamed diverticulum of the sigmoid which contained a piece of straw. Several illustrations of diverticula and of their microscopic appearance are appended. In one of the cases, a diverticulum of the caecum had become i88 PERICOLITIS infected with tubercle and caused tuberculous ulceration of the ascending colon. 2. Ulcer ATiox. — Any form of ulceration of the colon may cause pericolitis. The ulcers may be either single or multiple. The\' are generally of old standing, and have either perforated the bowel-wall or are covered on the outer side by peritoneum only. They are often cratiform, and the colon at the base of the ulcer has become adherent to other structures, or is densely matted over with fibrous tissue. In one of my cases in which the mucous membrane of the sigmoid was extensively ulcerated, the bowel- wall was so thick and hard as to suggest at first that it was the site of an infiltrating carcinoma, which view was apparently supported by the presence of numerous enlarged glands in the mesosigmoid. A careful examination, however, showed that the thickening of the bowel-wall was entirely secondary to the ulceration, and that the gland enlargement was inflammatory. 3. Perforation by Foreign Bodies. — These may be either pins, fish-bones, or other sharp bodies which have been swal- lowed, or foreign bodies introduced into the rectum. A case was recently reported in one of the medical journals, of a girl who had swallowed a packet of needles ; several of these were found to have reached the colon and perforated its walls, producing local adhesions and inflammation, but without causing a general peritonitis. A case is recorded by Cuff, in which a piece of straw, used by the patient for picking his teeth, was swallowed and perforated the colon. A chronic pericolitis occurred, and a hard mass formed in the abdomen and became adherent to the abdominal wall, and discharged pus. The pus was found on examination to contain the ray fungus : so that in this case the pericolitis was due to actinomycosis. 4. 5. Tubercle and Cancer. — These causes of pericolitis will be considered in detail in Chapters XIV and XVIII. 6. Syphilis. — This does not appear to be a usual cause of peri- colitis. It is mentioned, however, by one or two writers on the subject, and Cavaillon and Bardin have recorded four cases. 7. Traumatism. — The colon is not readily subject to injury from direct violence, and it is difficult to prove that a peri- colitis has arisen directly as the result of an injury. In two cases recorded by D'Arcy Power, there was a definite history of abdominal traumatism. In one, a woman had been kicked PERICOLITIS 189 in the abdomen, and in the other the patient had been struck in the abdomen wliile at work. In one or two other instances there are also liistories of abdominal injury, but in none of them was any tear or injurj^ of the colon demonstrated. Symptoms. These vary greatly, according to the cause of the condition and the degree of inflammation present. From a clinical point of view we may distinguish two distinct types : cases in which there is tumour formation, and those in which there is abscess. Thus in many patients the condition first draws attention to itself by the presence of a tumour in the abdomen, in others by signs of an intra-abdominal abscess, or by perforation and general peritonitis, while in a few the onset of intestinal obstruction is the first evidence of anything being wrong. Interest has chiefly centred round those cases in which a tumour forms in some part of the colon, as these tumours so closely simulate cancer of the bowel that they are usually mistaken for it. It is interesting in this connection to notice that many cases of supposed spontaneous disappearance, or cure without operation, of cancer of the bowel, are without doubt in reahty pericolitis in which the tumour has been mis- taken for cancer. These tumours are due to thickening of the bowel-wall from chronic inflammation. They grow slowly, and are often very hard, due to the deposit of fibrous tissue, so that it is usually impossible from the symptoms to distinguish them from malignant disease. Short of a microscopical examination, they cannot be diagnosed from cancer except in a few instances where the history may assist us, as in the following case :— Case. — Tlie patient was an elderly lady whom I saw in consulta- tion with her medical attendant with a view to the possibility of closing a colotomy opening of five years' standing. There was a history that about six years ago she commenced to have great difficulty in getting the bowels open. This gradually increased until it terminated in an attack of acute intestinal obstruction. For the relief of this a left inguinal colotomy was performed, and at the operation a large, hard, nodular tumour was discovered in the sigmoid flexure. This tumour was diagnosed as a large in- operable cancer, and the patient was not expected to live more than a few months. After the operation she got better, and had no 190 PERICOLITIS symptoms beyond those occasioned by the inconvenience of the colotomy opening. At the time I saw her, five years after the operation, she was in good health, and as some faecal material passed by the anus it was hoped that the colotomy opening might be closed. A sigmoidoscopic examination showed the rectum and lower part of the sigmoid to be normal, but above this the bowel was fixed, and there was a large mass in the bowel wall. From the colotomy opening, a large, hard, nodular mass could be felt in the bowel wall, but not invading the mucosa. It was firmly fixed, and adherent to the left iliac fossa. Just below the colotomy opening there was a tight stricture of the colon which would barely admit the tip of my index finger. The patient had never passed any blood, or experienced any symptoms pointing to ulceration of the mucosa. There is Httle doubt that this was a case of chronic pericolitis, due probably to diverticula. In the more acute cases, where there is abscess formation, the symptoms are exactly the same as those of appendicitis, except that the situation is different. Several of these have been described as appendicitis on the left side of the abdomen. There is a high or intermittent temperature, with rigors and sweats ; pain, localized to some part of the colon, and local peritonitis. A tender swelling may be present, and there may be fluctuation in this on careful palpation. The abdominal wall is rigid, and the patient lies with the legs drawn up and in considerable pain. If perforation has occurred, the usual symptoms of commencing general peritonitis will show them- selves. An exact diagnosis is seldom possible, but when we see a patient with all the symptoms of appendicitis, but with the signs localized to some other part of the abdomen than the appendix region, we should be suspicious of this condition. The following is a good instance of pericolitis with perforation : Case. — A caretaker, aged 57, was admitted to St. George's Hospital with symptoms of acute general peritonitis. There was a history of sudden abdominal pain following a dose of castor oil. On opening the abdomen it was found that the appendix was not the cause of the peritonitis, but the colon in the left iliac fossa was bound down by adhesions and was perforated. The abdomen was drained, but the patient died in a few hours. The autopsy revealed old adhesions and thickening of the pelvic colon, and a diverticulum which had perforated into the peritoneal cavity. There were numerous diverticula throughout the colon. The following, which is a good instance of pericolitis with PERICOLITIS 191 abscess formation, is recorded by Mr. D'Arcy Power {Brit. Med. Joiirn. Nov. 3rd, 1906) : — Case. — The patient, a married woman, aged 38, was admitted to the Bolingbroke Hospital, complaining of pain and a lump in her stomach. There was a history of her having been kicked in the abdomen on several occasions. Ten days before admission she was seized with severe abdominal pain quite suddenly while at work. During the following week the pain continued, and on one occasion she vomited. The bowels were, however, relieved daily. At the end of the week she suddenly became worse, and her tem- perature rose. On admission, her pulse was 128 and her temperature 102° F. The left side of the abdomen was rigid and tender, and a tumour could be felt to the left of and above the umbilicus. The abdomen was resonant over the swelling. A blood-count showed a marked leucocytosis. The abdomen was opened over the swelling, and a large abscess was found extending backwards to the posterior abdominal wall, and downwards along the inner side of the descending colon. The abscess was drained, and the patient made a good recovery. THE PATHOLOGICAL CONDITIONS ARISING FROM PERICOLITIS. Pericolitis may give rise to any of the following pathological conditions: (i) Tumour or swelling; (2) Abscess ; (3) Stricture of the colon ; (4) Adhesions to other organs ; (5) Fistulce ; (6) Vesico-colic fistulce ; (7) Cancer ; (8) General peritonitis ; (9) Deformities and, contractions of the mesosigmoid. I. Tumour Formation, — Chronic pericolitis may result in the formation of a tumom" which to the naked eye is indistinguishable from a malignant growth, and in many instances it has only been on microscopical examination that the true pathology of the condition has been detected. The tumour is usually very hard, irregular in shape, and adherent to neighbouring structures. The lymphatic glands draining the affected area are usually enlarged. On examination after removal, either as the result of an operation or " post mortem," evidence of inflammation is usually noticed. The mass may be red and oedematous in places, while here and there white patches of lymph can often be seen, which mark the site of recent adhesions to neighbouring structures. The peritoneum is usually rough and much thickened. When cut open the walls are seen to be thickened 192 PERICOLITIS and indurated, and to the naked eye may closely resemble a malignant growth. In some instances the wall of the bowel has been an inch or two in thickness, and intensely hard. Thickening is due to inflammatory infiltration of all the coats of the bowel, and subsequent formation of fibrous tissue. In fact the entire bowel-wall may be converted into a solid mass of fibrous tissue over an inch in thickness. The thickening is not confined to any one aspect of the bowel-wall, but in most cases completely surrounds it, though it is often considerably greater in one part than another. The mucous membrane may be almost unaffected, and on examination be quite smooth ; in this respect it differs markedly from the condition usually seen in cancer. The presence of diverticula or ulcers may often be detected on careful- examination, as the condition has generally arisen from some cause within the bowel. There is often narrowing of the bowel lumen at the site of the tumour, and this may have resulted in secondary ulceration in the bowel above the stricture from faecal retention. This, however, must not be confused with the primary cause of the condition. The stricture itself is a secondary result of the formation and subsequent contraction of the fibrous tissue in the wall of the colon, and in this respect closely resembles the formation of the typical ring stricture often seen in cancer of the colon. There may be only a ring stricture, or in some cases a long narrow canal is formed. In some, the lumen has been so narrowed as barely to admit a lead pencil. In others, however, considerable tumour formation occurs, with but little narrowing of the bowel lumen. Curiousl}^ enough, the mucous membrane may not be involved at all in the inflammatory process, even though apparently the condition has arisen from some defect in the mucous lining of the canal. Thus in one case, although a considerable tumour existed, and the walls of the bowel were over half-an-inch thick, the mucosa showed no changes, and moved freely on the sub- jacent coat. The thickened walls of the bowel may show necrotic or break- ing down areas, but this is the exception rather than the rule. Careful examination of the walls of the bowel after it has been cut open will not infrequently reveal the presence of diverticula or pouches, usually multiple, and often very narrow. PERICOLITIS 193 Microscopical Appearances. — The tumour is generally seen to consist mainly of a dense mass of fibrous tissue and round-celled infiltration, quantities of round cells being interspersed here and there throughout the mass. At the areas of more active or recent inflammation the ordinary appearances of chronic inflammation may be seen, namely, loose connective tissue crowded with lymphocytes. Areas containing necrotic tissue or blood extravasation may also be found. The peritoneum shows chronic inflammatory changes, is usually much thickened, and the muscular coat much atrophied. The mucosa often shows comparatively httle change, but in some cases is a good deal atrophied, the glandular elements having disappeared. 2. Abscess, — This is a not uncommon result of pericolitis. The abscess may be single, or there may be a large indurated, mass containing numerous small abscesses. These are similar to abscesses accompanying appendicitis, and are usually shut off from the general peritoneal cavity by adhe- sions to neighbouring coils of bowel. The abscess may be post- peritoneal, in which case it is often very extensive, surrounding; the kidney, and passing up to the diaphragm and down into, the pelvis. The formation of a post-peritoneal abscess seems, to be most often associated with pericoHtis of the ascending colon. They may burst externally, or into the bowel, or may rupture into the peritoneal cavity ; instances of all these con- ditions have been met with. Such abscesses are also a not uncommon cause of vesicocolic fistula. As is the case with appendicitis, they may result from an actual perforation of the bowel, or may arise without any perforation being detectable : presumably from the passage of micro-organisms along the lymphatics, or even through the damaged bowel-wall. A common cause is perforation of a false diverticulum of the colon. In a case recorded by Telling, acute intestinal obstruction had resulted from the small bowel becoming adherent to a mass of pericolitis in the sigmoid flexure. A short-circuiting operation was performed, but the patient died. It was then found that there were several diverticula in the sigmoid, some of which had perforated and caused adhesions to the ileum. Another case is recorded by Moynihan, in which also the ileum had become adherent to the sigmoid as the result of pericolitis, with resulting acute obstruction. The patient died 13 194 PERICOLITIS five dav3 after a double enterotomy had been performed. There is a specimen in Guv's Hospital Museum of a band between the sigmoid flexure and the mesentery of the ileum. The band is formed bv two adherent appendices epiploicae, and there is some thickening of the wall of the sigmoid. The patient died from intestinal obstruction. Tuttle records a case of chronic obstruction resulting from Idnking of the sigmoid flexure due to two appendices becoming adherent to each other as the result of local pericolitis. 3. Stricture. — In man}- instances a fibrous stricture giving rise to obstruction has been the cause of death, or has called for the performance of an operation for its reHef. The amount of narrowing of the colon may be very considerable, and as the commonest situation for the condition is in the sigmoid flexure, where the bowel contents are usually soKd, obstruction readih- occurs. 4. Adhesions. — Extensi\'e adhesions of the affected portion of bov.el to surrounding structures are the rule in pericolitis, and are nature's method of protecting the patient from the consequences of the condition. Favel tells of a woman who suffered from persistent pain in the abdomen, vs'hich was found on performing laparotomy to be due to extensive adhesions between the ascending colon and the anterior abdominal wall. In another case, in which the patient suffered from constant pain and frequent vomiting, adhesions were found between the ascending colon and the abdominal wall, involving also the uterus. In both cases the adhesions had arisen from a localized pericoHtis of the ascending colon. Intestinal obstruction resulting from adhesions produced by pericolitis may occur, and is generallv due to adhesions between the small intestine and the colon. 5. Fistulae. — These maj^ form from the formation of an abscess which opens upon the abdominal wall, producing a cutaneous fistula, or a communication may take place into some other hoUow viscus, such as the stomach or small intestine. 6. Vesico-colic Fistula. — One would naturall}- expect peri- colitis, when it aft'ects the sigmoid, to be a common cause of adhesions between this viscus and the bladder, with which it is in close contact, and that the subsequent formation of a PERICOLITIS 195 fistula between the two would be a not uncommon complica- tion. This was actually present in sixteen of my collected cases. There is an interesting example in Guy's Hospital Museum. The patient was a man aged 65, who for twelve years had passed flatus " per urethram." More recently faeces had commenced to escape from the urethra. Mr. Bryant performed colotomy, but the patient died. Post mortem a much thickened sigmoid flexure was found, in the walls of which were numerous diver- ticula. A fistula some two inches in length established com- munication between the bladder and the sigmoid. Pericolitis is probably the commonest cause of these fistulas, as was pointed out by Mr. Harrison Cripps many years ago, when he showed that the cause was inflammatory in 45 cases out of 63, and malignant in only nine, though it seems generally believed that malignant disease is the commonest cause of these fistulas. Chavannaz, from a study of 95 cases, came to 'the conclusion that 24 per cent only were due to malignant disease. Telling, after a careful investigation of the subject, concludes that pericolitis arising from diverticula of the colon is the commonest cause of these fistulae, and points out that this much improves the prognosis as regards operative interference. 7. Cancer. — I have seen one case in which there was a cancer at the recto-sigmoidal junction associated with several large diverticula of the sigmoid, and pericolitis. The greater part of the sigmoid showed considerable simple inflammatory thicken- ing. It was impossible to be certain that the pericolitis was the primary condition, but it appeared probable. A case was reported by Hochenegg in 1902 of a patient with cancer of the sigmoid flexure. The whole of the sigmoid flexure being the site of numerous diverticula containing feecal con- cretions, he assumed the cancer to have arisen from the irritation of the faecal material in the diverticula. A case in which a carcinoma of the splenic flexure was associated with numerous diverticula in the sigmoid flexure, and in which the appearances of the growth suggested it had arisen from a diverticulum in the splenic flexure, is reported by TelHng. We know that carcinoma of the appendix may occur ap- parently as the result of chronic inflammation around a retained calculus in the appendix, and it seems equally probable that a 196 PERICOLITIS similar result may follow a chronic pericolitis from retained fsecal material in a diverticulum of the sigmoid flexure. 8. General Peritonitis. — General peritonitis is a common result of pericolitis, and the usual cause of death from this disease. It may result from a direct perforation of the wall of the colon due to ulceration, or to sloughing of the end of a diver- ticulum of the colon from rupture of a pericolic abscess into the peritoneal cavity. In one case a faecal concretion was found loose in the peritoneal cavity, and on the anterior aspect of the sigmoid flexure there was a diverticulum which was partly gangrenous. Most cases of pericolitis which have been left untreated have died of general peritonitis. In some of these it had not been possible to demonstrate any opening through which infection could have reached the peritoneal cavity, and the abscess, if present, was apparently shut off. In these cases we must assume, either that the opening had been overlooked, had been closed again before death, or that the organisms had passed through the walls of the abscess without perforation being present. 9. Deformities and Contractions of the Mesosigmoid. — It is obvious that if chronic inflammation occurs in and around the wall of the sigmoid flexure, the mesosigmoid will be liable to be involved in the subsequent contraction caused by organized fibrous tissue. This arises not uncommonly, and the meso- sigmoid may be shortened, contracted, or otherwise deformed to a considerable extent as the result of an old-standing peri- sigmoiditis. Such contractions may be of no consequence to the function of the bowel, but occasionally may result in kinking or angu- lation of the sigmoid, or in such impaired mobility that a serious impediment to the passage of the faeces results. In this way actual acute obstruction — or more frequently a chronic obstruction — is produced. This subject has already been con- sidered in dealing with volvulus and angulation of the pelvic colon. The effect of a meso-sigmoiditis in producing obstruction, twists, kinks, and other deformities has been pointed out by Reis, Tixier, and Riedel. Reis beheves that the meso-sigmoiditis is produced by mesenteric diverticula, which have become inflamed, but no direct proof of this point is recorded. PERICOLITIS 197 Treatment of Pericolitis. To judge by the cases I have been able to collect, pericolitis appears to be a very fatal disease, 70 per cent of the patients having died either from general peritonitis, obstruction, abscess, or pyaemia. This high mortality must not be attributed, however, to surgical failures, as in many cases no operation was performed, but rather to the absence of a correct diagnosis. The successful treatment of pericolitis, like that of appendicitis, depends to a very large extent upon correct and early diagnosis of the condition. The great majority of cases hitherto have been diagnosed only at an operation, or as the result of a post-mortem examination, and the first essential of successful treatment in dealing with this disease is to get it better recognized, and to obtain a reasonable probability of a correct diagnosis, before the case has advanced too far for operation to be attended by a reasonable possibility of success. Of the 74 cases which I have been able to collect, 35 were not operated upon, and 39 were. Of those that were not operated upon 33 died, and only 2 recovered, while of the cases operated upon 21 recovered and 18 died. It must, however, be remembered in considering these figures that a diagnosis has seldom been made except as the result of either an operation or a post-mortem examination, and that in consequence there is in all probability an undue proportion of deaths among the unoperated cases. These, however, show clearly that there is little to be hoped for from purely medical treatment, a view supported by the fact that death has in most cases been due to general peritonitis, a condition not amenable to purely medical treatment. The only hope is clearly in early operative interference. Of the cases operated upon, 18 died, that is to say, there was an operative mortality of 44 per cent. This is high, and should be much reduced, but it is not surprising when we consider that in most instances a correct diagnosis was not made previous to operation. Also in several cases the operation was merely an exploratory one, and the abdomen was closed without anything being done. Of 5 cases so treated 4 died. Again, in 7, colotomy was per- formed under the impression that the case was one of inoperable cancer, and of these 4 died. 198 PERICOLITIS The accompanying table shows the results of the various operations that have been performed for pericolitis. Nature of Operation. No . OF Cases. No. OF Deaths. Exploratory Laparotomy . Colotomy i^^ Excision ii ■ . . Drainage Division of adhesions Short-circuiting Various . . 5 7 12 5 3 2 5 4 5 3 I 2 3 Colotomy failed because in all but one of the cases there was an abscess in connection with the colon, and although the colotomy relieved the obstruction, the abscess remained and caused peritonitis. Simple drainage appears to have been very successful, as out of 5 patients so treated 4 recovered. These were all cases of a localized abscess in connection with the colon. Excision of the entire inflamed portion of colon was performed 12 times, with 9 recoveries. The causes of death after operation were as follows : — ' General peritonitis . . . . 14 cases Pyaemia (not due to operation) . . i case Obstruction (unrelieved) . . . . i case Cardiac failure (on eighth day) . . i case The treatment of pericolitis is practically the same as for appendicitis, and as with the latter condition, the nature of the operation must to a large extent depend upon the exact patho- logical condition present, and the acuteness or otherwise of the disease. Very frequently the symptom necessitating immediate operation has been the development of a local or general peri- tonitis, due either to abscess formation, or to perforation of the bowel into the peritoneal cavity. Localized Abscess. — The obvious treatment is to open the abscess and adequately drain it, while at the same time preserving as far as possible the natural adhesive barriers protecting the general peritoneal cavity. The abscess may be very extensive, and for adequate drainage to be established it may be necessary to make a counter-opening in the loin. PERICOLITIS 199 When dealing with an abscess in the bowel-wall there may be much difficult}^ in locating it owing to the dense mass of sur- rounding adhesions. This is well exemplified by several of the cases in which, after an exploratory laparotomy had been performed without any abscess being discovered, the post-mortem examination showed such to have been present. Perforation and General Peritonitis. — In these cases, though a careful toilet of the peritoneum and the establishment of adequate drainage may suffice, it is advisable, if possible, to find, and close by sutures, the perforation in the colon. Where the perforation is due to the rupture or sloughing of a diverticulum, the perforation may not be single, or other diverticula may be so nearly in the same condition as to threaten to perforate. Also when, as often happens, the perforation has occurred in a dense mass of fibrous tissue and adhesions, very great difficulty may be experienced in closing the perforation. I have been unable to find a single instance of perforating pericolitis, in which the general peritoneal cavity was infected, which has been successfully operated upon. And yet in no less than 20 of the cases, death was directly due to general peritonitis following a perforation of the colon directly into the peritoneal cavity. This is without counting those cases of general periton- itis due to the secondary bursting of an abscess. Perforation has most frequently resulted from the sloughing or rupture of a diverticulum, usually upon the free border of the sigmoid colon. Intestinal obstruction was the cause of death in 7 cases, and pj/a^mia in 3. The best results have been in cases accompanied by tumour formation. The tumour has in almost every instance been diagnosed as carcinoma previous to operation, and in several instances its inflammatory nature has remained undetected until a microscopical examination has been made. Here again we see the importance from the point of view of treatment of a correct diagnosis. The collected cases show clearly that in quite a number of instances the surgeon has abandoned the operation under the impression that he was dealing with a hopeless case of cancer of the bowel ; whereas, had he known that he was only confronted with a simple inflammatory tumour, he might have successfully resected it. Out of 12 cases treated by resection and end-to-end anasto- mosis, or the establishment of a colotomy, 9 recovered. 200 PERICOLITIS Moynihan resected seven inches of the transverse colon for pericoHtis, and subsequently anastomosed the ends in one case, and in another resected five inches of the sigmoid flexure. Mayo excised eight inches of the sigmoid in one case, and in another ten inches of the descending colon and sigmoid flexure. REFERENCES. RoLLESTON. — Lancet. April, 1905. Moynihan. — Edin. Med. Jour. Mar. 1907. Roberts. — Brit. Med. Jour. May 26, 1908. Brewer. — Amer. Jour. Med. Sci. Oct. 1907. Saillant. — Jour, des Praticiens, July^ 1906. Thomson. — Lancet, Mar. 21, 1908. Telling. — Lancet, Mar. 21, 1908. 201 Chapter XIV. TUBERCULOSIS OF THE COLON. Tuberculous lesions of the colon are not uncommon. Thus Eisenhardt, out of i,ooo tuberculous subjects, found such lesions of the intestine in 56 per cent ; in most of these the colon was affected. In all but four of his cases the condition was secondary to phthisis. Similarly, Herscheimer found it present in all but one out of 58 cases of phthisis. In considering these figures, however, it must be taken into consideration that practically all these patients had either died from, or were under treatment for, phthisis. Also they only refer to the ordinary ulcerative, and usually secondary, form of intestinal tuberculosis. There can be no doubt that this form of ulcerative cohtis is a common secondary complication of phthisis, and the infection is probably caused by the sputum which is swallowed. There are three types of tuberculous disease of the colon : — (i) Where it forms part of a general or miliary tuberculosis ; (2) Tuberculous ulceration ; (3) Hyperplastic tuberculosis. Tuberculous Ulceration of the Colon (Tuberculous Colitis). — In the ulcerative type, the infection is certainly secondary in most cases to tuberculous lesions of the lungs and air-passages, or the higher parts of the alimentary canal, and is due to direct infection of the mucous membrane with tubercle bacilli. I have been unable to find any case of primary tuberculous ulceration of the colon, and it seems probable that it is always a secondary tuberculous manifestation due to direct infection. In not a few cases it is the chief lesion which calls for treatment. In one case it was apparently secondary to tubercle of the genito-urinary tract. Rarely, however, tuberculous ulceration of the colon may exist apart from evidence of general tuberculosis. Cautley has recorded the case of a girl, four years of age, who had been ill for a year. During six months the stools had been frequent, loose, and very offensive, and for 202 TUBERCULOSIS OF two weeks they had contained small black particles of clotted blood. Vomiting occurred daily, but there was practically no abdominal pain or distention, and no fever. She died ; and at the autopsy two tuberculous ulcers, causing stricture, were found in the colon. There were also extensive ulceration of the caecum and multiple ulcers in the small intestine, with a little adhesive peritonitis at their bases, but no caseous mesenteric glands. A small old caseous nodule was found at the apex of the left lung. The ulceration in these cases is of the typical tuberculous type, with overhanging edges and a raw, unhealthy base. On micro- scopic examination, numerous caseating areas can be seen, and tubercle bacilli are present in great numbers. The ulcers are usually multiple, and often extensive, tending to encircle the bowel ; as a rule there is little or no thickening of the bowel-wall, in which respect it differs markedly from the hyperplastic type of lesion. Secondary deposits of tubercle, and caseation in the mesenteric glands, are common ; though in one case there was no infection of the glands. The ulcers may occur in any part of the colon, but are most commonly seen in the csecum and ascending colon. The ulcers may perforate the bowel wall, and cause either abscess, fistula, or general peritonitis. In four of the cases of perforating ulcer of the colon which I collected the ulceration was tuberculous. A remarkable case is reported by Grey Turner* in which tuberculous ulceration of the ascending colon apparently resulted from infection of a false diverticulum of the caecum. The wall of the diverticulum was infiltrated with tubercle, and the ulcera- tion had extended into the surrounding tissues. While the formation of a stricture as the result of tuberculous ulceration of the ileum is common, it very rarely occurs in the colon. Fistula formation is, however, not uncommon. The fistula may open on to the skin surface, into another part of the bowel resulting in a short circuit, or into the vagina, rectum, or bladder. Hyperplastic Tuberculosis of the Colon. — The hyper- plastic form is, apparently, in some instances a primary tuberculous lesion ; in most of the recorded cases there were * Lancet Report, i6, 1905. THE COLON 203 no S5miptoms of tuberculosis elsewhere, and in two or three of them an autopsy was made, and a careful examination failed to jeveal any other lesion of the kind. Also in a considerable number of the hyperplastic cases there is no ulceration and the mucous membrane is intact. It is a very disputed point in these cases whether the tubercle bacillus reaches the colon wall from the bowel lumen or by the blood-stream. Hyperplastic tuberculosis of the colon is definitely a surgical disease, as it gives rise to tumour formation and stricture of the bowel, and the only rational treatment is by operation. It has been repeatedly "mistaken for cancer, which in symptom- atology it closely resembles ; but has seldom been diagnosed previous to operation, and often only then after a microscopical examination. The lesion is very rare ; there is not a single specimen in the Royal College of Surgeons Museum, and it is not mentioned in most surgical or medical text-books. This peculiar form of intestinal tuberculosis was first described in detail by Hartman and Pilliet in 1891. It is of particular interest for two main reasons : First, that it is a manifestation of tubercle quite unlike the lesions usually met with in other organs ; secondly, because it is quite commonly mistaken for carcinoma of the bowel. In fact, there is little doubt that a great many of the cases of supposed cancer of the bowel which have got well without operation, or after such operations as short-circuiting or colotomy, were really cases of this disease. They will, however, be referred to again later. There is much difficulty in studying this disease, as it is hardly yet recognized generally, and consequently cases are often described under some other heading, or simply recorded as rare conditions ; in many no proper microscopical examination has been made for tubercle bacilli in the tissues. Though the condi- tion is undoubtedly a rare one, I have been able to find many well-authenticated cases. The disease appears to occur with about equal frequency in the two sexes. Thus, out of my series of 100 cases, 47 were males and 33 females. In Bernay's 71 collected cases there wxre 40 men and 31 women. Conrath collected 77 cases, and found 36 men and 41 women. This affection chiefly attacks those in the middle period of life. 204 TUBERCULOSIS OF between 20 and 40 years of age. This corresponds very closely with the average age for phthisis. In my series the average age is 32 ; the oldest patient is 78 and the youngest 7 years of age. It is generally localized to one part of the colon ; occasionally, however, there are two or three distinct lesions ; and in a few very rare cases the whole or a large part of the colon is affected. It may arise in any portion ; but by far the commonest situa- tion is the caecum and lower part of the ascending colon. The appended table shows the distribution in my collected series of 100 cases : — Sigmoid flexure . . Caecum . . Caecum and ascending colon Whole colon Caecum, ascending and transverse colon Total 39 4 3 There appears to be no explanation why the caecum is the most commonly affected portion. The characteristic feature is the formation of a tumour in some part of the colon, accompanied by stricture of the bowel lumen. The disease is essentially chronic, the inflammation encouraging the formation of fibrous tissue and thickening, rather than caseation or ulceration. In many cases the mucous membrane is quite intact, and there is no sign of ulceration. The bowel- wall, however, becomes in time greatly thickened, with the formation in most cases of a definite tumour. Constriction and stricture of the bowel may ensue and cause intestinal obstruc- tion. Secondary abscess may occur ; but this is unusual. Tuberculous peritonitis is likewise uncommon. The disease differs very much from common tuberculous lesions, and resembles certain rare cases of tubercle of the skin and larynx, and especially those cases of Hodgkin's disease which, post mortem, have been found to be tuberculous. As a rule there is a single tumour ; but in a few cases there have been several. Trendelenburg has reported a case in which there were five distinct strictures of the colon from this cause ; and Borch one in which there were four. Association with other Tuberculous Lesions. — As a rule, the condition of the colon is the only manifestation of tubercle THE COLON 205 to be found ; in only twenty-four out of the one hundred cases I have collected was there any evidence of tubercle elsewhere. In several of these it seems almost certain the other lesion was secondary to that in the colon. Table of 100 cases : — No other tuberculous lesion . . . . 76 Tuberculous cavity in lungs or scars of old phthisis iS Tuberculous peritonitis . . . . . . i Tubercle of tibia . . . . . . i of genito-urinary tract . . . . 2 of phalanges . . . . . . i Tuberculous ulcer in vagina . . . . i It seems evident, therefore, that in most of the cases the disease is a primary tuberculous lesion. When the caecum is the affected region the appendix is not as a rule primarily involved, though it not infrequently becomes so secondarily. Morbid Anatomy. The most characteristic lesion is the formation of a tumour in some portion of the colon. The most usual situationTif ~Thi i:kenin g"~isTocalized to^gnirpart of the colon, is the caecum, especially in the neighbourhood of the ileocecal valve. Some- times, however, the transverse colon, or sigmoid, have been alone affected. In a case reported by Claude, the ascending and descending colon were affected, but the transverse colon was free. In others the greater part of the colon has been involved, and in Lartigau's case the greater part of the small intestine as well. Commonly, the affected portions of bowel are matted in a mass of fibrous adhesions and enlarged lymphatic glands, so that often a large tumour is produced. The most conspicuous feature is the thickening of the colon wall, which is very marked in all cases. In this it differs widely from other forms of tubercle of the bowel, as instead of there being a destruction of tissue with thinning, there is usually no ulceration, but great thickening and new formation. The bowel- wall feels firm and hard, due to infiltration with round cells and the deposit of fibrous tissue. This spreads equally round the . circumference of the bowel-wall, so that in extreme cases the 206 TUBERCULOSIS OF bowel is converted into a hard tube almost resembling a gas-pipe ; considerable narrowing of the lumen follows as a result of the disease ; and in most cases stenosis results, and chronic or acute obstruction. Stenosis is the common feature, and the bowel lumen may be so completely blocked that it cannot be detected post mortem. Even where no definite stenosis is present, the thickening of the bowel-wall ultimately prevents the peri- staltic movements from taking place, and obstruction results from this cause. In addition to the formation of stenosis by h5^erplasia of the bowel-wall, narrowing of the lumen may occur from the contraction of ulcers, and from kinking of the bowel by the contraction of adhesions. Where the stenosis and thickening are local, considerable Fig. 51. — Hyperplastic tuberculosis of the colon (/I/?-. Nash's case). dilatation of the colon above the stricture may occur, and secondary stercoral ulcers may form. Commonly the mucous membrane appears normal and there is no ulceration or breach of the surface. Sometimes the mucous membrane is ulcerated. This is most frequent where there is stricture of the bowel lumen, the ulceration being often confined to the strictured area. This has led some observers to conclude that the stricture is the result of ulceration, which it certainly is not, as some of the cases where there is marked stricture show no ulceration. In many, the ulceration is the ordinary form of septic or traumatic stercoral ulcer found above a stricture of the bowel. In fact, the ulceration, though it may occasionally be tuber- culous, is probably most often a secondary result of the stricture. THE COLON 207 The mucous membrane is usually thickened, and may show numbers of small tubercles scattered over its surface. A striking feature in many cases has been the formation of polypoid or papillomatous outgrowths on the mucous membrane. The polypoid growths are usually pedunculated, and hang free in the bowel lumen. Similar sessile tumours are sometimes present in addition, which suggests that this is the early form of the pedunculated polypi. Polypoid growths are often very numerous, and give a most curious appearance to the bowel. They vary in size from quite small round polyps to those as large as hazel-nuts. They are covered over with a layer of Fig. 52. — Hyperplastic tuberculosis of the colon. The bowel has been cut open longitudinally. epithelial cells similar to the surrounding mucous membrane, and their centre is continuous with the submucous layer of the bowel-wall, and consists of connective tissue and round-celled infiltration. Occasionally there are caseous foci in the centre of these polypoid growths which may in places have ulcerated through the epithehal layer. The tumour is very hard and densely indurated. The peri- toneum, as a rule, appears normal to the naked eye, though in some cases it is covered with small raised tubercles or nodules of a reddish colour. If the mass is cut open, the walls of the bowel are seen to be 2o8 TUBERCULOSIS OF greatly thickened, often to an inch or more, and look and feel like cartilage. The cut section has often a curious bluish-grey translucent appearance, and a glistening surface. The muscular coat is generally much thickened and can be distinctly seen. Often the greatest thickening is in the subserous layer, which consists of greyish translucent fibrous tissue of cartilaginous hardness, with irregular-shaped areas of yellowish tissue here and there. The bowel lumen is usually markedly strictured, or there are outgrowths into it. The whole tumour is often very vascular ; in some cases it shows areas of degeneration or caseation. Two types of lesion have been described, the submucous and subserous, according as the thickening and induration are chiefly in the submucous or subserous layers. Both conditions, how- ever, may be seen in the same case, and there seems little advan- tage in making a distinction between these two forms. The disease often so closely resembles cancer of the colon that it is only distinguished from it on microscopical examination. Histology. — The mucous membrane often shows little if any change beyond some thickening. Cells undergoing mucoid or cystic degeneration are not infrequently seen. If ulceration is present, the mucous surface presents a mammillated appearance, or is altogether absent. Polypoid growths, if present, are seen to be outgrowths from the submucosa, and their centres are continuous with it. The epithelium covering them is the same as the normal epithelium, except where ulceration is present, or unless caseation has occurred. The submucosa is generally markedly thickened by round- celled infiltration and the formation of dense fibrous tissue. Tubercles and giant cells are often to be seen in this layer in considerable numbers. Large polymorphonuclear round cells, and coarsely granular eosinophile cells are also to be seen, especially towards the mucous membrane. There may also be caseating tuberculous foci in this layer. The predomin- ating feature is, however, round-celled infiltration with fibrous tissue. There is always much thickening of the muscular coats, due chiefly to small round-celled infiltration. It is doubtful whether there is really any increase in the number of muscle fibres such as would constitute a true hypertrophy. Some observers claim THE COLON 209 that there is, while others are equally emphatic that there is not. If dilatation has occurred above the stricture, the muscular coat may be h\^ertrophied ; but apart from this, the hypertrophy appears to be due chiefly to increase in the connective tissue between the fibres. The subserous layer is often greatly thickened owing to new connective-tissue formation. There is a dense mass of fibrous tissue and small round cells. There are numerous new blood- vessels, often with thick walls. This layer often contains large vacuolated spaces holding yellow fatty tissue. Giant cells and areas of caseation are much less numerous here than in the submucous layer. The serous layer shows very little change, though it may be much thickened. Tubercle bacilli can usually be found in the submucous layer if; sections are carefully stained ; compared with other tuberculous, lesions, however, they are very scant\^ They may be found in. large numbers in a section from one part of the tumour, and not at all in a section from another ; while in several cases they have: been looked for with great care in vain. Portions of the growth: have in several instances been inoculated into animals and. caused tuberculosis. Symptoms. Tuberculous ulceration of the colon gives rise to the ordinary symptoms of ulceration of the bowel, and does not differ in this respect from the non-tuberculous forms of ulcerative coHtis. As already stated, it usually occurs as a terminal condition in the later stages of tuberculosis of the lungs. The occurrence of diarrhoea and bloody stools, combined with well-marked signs of phthisis, is indicative of the onset of this condition. Occasionally single ulcers may form and perforate, and in a few instances general peritonitis has occurred from the per- foration of a tuberculous ulcer in the colon. The symptoms of hyperplastic tubercle of the colon are those of a chronic pericohtis. A tumour slowly develops in the abdominal cavity, usually in the csecal region, and is accompanied by a varying amount of pain and tenderness. In some cases, however, there is Little, if any pain, and the tumour is the only sign of anything wrong. Sooner or later the patient either has recurring attacks of partial obstruction, or an acute attack of complete obstruction. In a large number of instances there are 14 210 TUBERCULOSIS OF sjnnptoms of tuberculosis, either in the lungs or elsewhere, but in about a quarter the condition is apparently primary in the colon. It is obvious that the symptoms of hyperplastic tubercle of the colon are the same as for cancer of the colon ; and as the latter is the more common disease, it is hardly surprising that the vast majority are diagnosed as cancer. In hyperplastic tubercle of the colon there is seldom any bleeding ; but in cancer, while bleeding is not invariable, it is usual. The complete absence of blood in the stools, even on microscopical examination, is slightly in favour of tubercle, more especially if the tumour has existed for some time. Tubercle bacilli can only with difficulty be discovered in sections of the colon wall, and are practically never found in the stools. Secondary Lesions. — Stricture is an almost invariable accom- paniment of the lesion. It is due mainly to the contraction of the fibrous tissue in the bowel wall, and sometimes partly to outgrowths into the lumen. The amount of narrowing of the lumen is often considerable, and the bowel may be almost blocked. Intestinal obstruction is a common terminal result. As already stated, when ulceration is present it is probably in most cases a stercoral ulceration secondary to the stricture, though sometimes due to caseation of the submucous layer and conse- quent destruction of the mucous membrane. Dilatation and hypertrophy of the bowel above the stricture is common, and stercoral ulcers in the dilated portion of bowel have been present in several patients. In one case recorded by Crowder the tumour had apparently undergone secondary malignant change. It was situate in the -caecum, and presented the typical appearances of hyperplastic tuberculosis with giant cells and tubercle bacilli. In one part the epithelial cells had penetrated to all depths of the tissue, and there were masses of atypical epithelial cells forming tubercles. Apparently the tuberculous lesion was the primary one, and part had undergone secondary malignant change. The glands are usually enlarged, and show giant cells and caseating areas ; but in several cases there was no gland enlarge- ment. In many, the tumour was tied down by dense adhesions, and, in some, abscess and fistula had formed. These complica- THE COLON 211 tions, however, generally mark an advanced stage of the disease, when stricture and secondary ulceration have occurred, and are in no way typical of the condition. The following case is reported by Cumston.* Case. — The patient was a woman, aged 87, who had complained of pain in the right iliac fossa for eighteen months. She also suffered severely from constipation, and had lost flesh. There was a large mobile tumour in the right side of the abdomen. On opening the abdomen, a tumour in the caecum was discovered. The ceecum was resected, with 8 cms. of the ileum and 6 cms. of the colon ; the ends were closed, and rejoined by lateral anastomosis. The patient made a good recovery, and was well nineteen months later. Examination of the specimen showed a cauliflower-like tumour the size of a small apple. On the upper aspect of the ileocsecal valve it completely obstructed the bowel lumen. The cascal walls were much thickened, and this thickening extended for some distance into the colon. The mucous membrane was intact. There were a few enlarged glands in the mesentery. Microscopical sections of the tumour showed the appearances of tuberculosis. The following cases were reported by F. S. Kidd : — Case. — The patient was a girl, aged 7. Three years previously she developed an ulcer in the vagina, which appeared to be tuberculous, and a faecal fistula formed. Several operations performed with the object of closing this fistula had failed. The abdomen was opened, with the object of performing colotomy, and it was then found that the sigmoid flexure was represented by a hard, indefinite mass about 6 in. long. The whole mass was very vascular. It was diagnosed as cancer, and was brought out of the abdomen, and an artificial anus established. A few days later the growth was cut away. The child recovered with an artificial anus. Examination of the specimen showed a tight stricture two-and- a-half inches long. There was some ulceration at the site of the stricture, but elsewhere the mucous membrane was normal. The subperitoneal layer of the bowel wall was greatly thickened, and had undergone a curious transformation into pale bluish hyaline tissue almost as hard as cartilage ; in places this was nearly two inches in thickness. Microscopical sections showed fibrillae, fibro- blasts, and round-celled infiltration. There were also numerous large endothelial cells. Sections were stained for tubercle bacilli, * Annals of Surg. Nov. 1907. 212 TUBERCULOSIS OF but they could not be demonstrated ; the condition was, however, evidently hyperplastic tuberculosis. Case. — The patient was a man, aged 57, who died of intestinal obstruction. Post mortem there was a tuberculous scar at the apex of the right lung. At the lower end of the sigmoid flexure there was a hard cartilaginous mass involving the bowel and causing a long narrow stricture. Examination of the tumour showed the mucous membrane to be intact. There were two or three large polypoid masses, which had become impacted in the narrow lumen and caused obstruction. The muscular coat was hypertrophied, and the subperitoneal coat in some places measured as much as three inches in thickness. It was as hard as cartilage. ^Nlicro- scopical sections showed fibrillar tissue and fibroblasts. There was much small-celled infiltration, with numerous large poly- nuclear cells. "Gas-Pipe Colon." — There are a few very rare cases of hyperplastic tuberculosis of the colon in which the whole or the greater part is uniformly thickened and densely indurated, and for want of a better term I have called these cases " gas-pipe colon," owing to the resemblance of the bowel to a piece of iron gas-pipe. I have been able to collect four of these curious cases, one of which I saw myself, and three are from other sources. The close resemblance between the four makes it certain that they were all of the same nature. One was reported as a case of diffuse carcinoma ; but it seems certain, from the resemblance to the others and from the fact that symptoms had existed for fourteen years, that it was really hyperplastic tuberculosis. In my case the patient was a lady, aged 72, who was supposed to be suffering from intestinal obstruction due to cancer of the rectum ; some resistance could be felt high up in the bowel. On opening the abdomen to perform colotomy, it was discovered that the entire large bowel, from the rectum to the cacum, consisted of a hard tube with non-collapsible walls, resembhng more than anj^thing else a piece of iron gas-pipe. The colon was diminished in size, being barely an inch in diameter in many places. It was bound down to the posterior wall of the abdomen, and everjAvhere quite immovable. The walls of the colon were as hard as stone, and nodular. The peritoneal surface of the bowel was covered over with small pink tubercles, and there was THE COLON 213 much ascites. The wall of the caecum was greatly thickened ; but not in the same way as the rest of the bowel. The lumen was evidently patent, because the bowels had acted occasionally for some weeks, and slightly the day before the operation. The small bowel was normal. Colotomy could not be performed ; but a Paul's tube was tied into the c^cum with difficulty. The patient died, but no post- mortem was obtainable. The most complete case is Lartigau's. The patient was a man, aged 49, who died after a three years' illness. The thicken- ing of the bowel wall commenced in the upper third of the ileum , and extended throughout the colon to the commencement of the sigmoid flexure. The wall of the bowel was 27 cms. thick, and uniform throughout. The lumen was patent, and contained numerous papillomatous masses. Microscopical sections of the bowel wall revealed fibrous thickening, and sections stained for tubercle bacilli showed them to be present in large numbers. There was no ulceration of the mucosa. C. Briddon's case* was that of a man, aged 34, who for twelve years had been suffering from constipation, painful defaecation, and occasional bleeding and tenesmus. This condition had continued with exacerbations. When admitted to the hospital he had six to eight stools daily, which contained blood and mucus and were offensive. Per rectum an indurated mass could be felt. An attempt was made to perform a left inguinal colotomy, but the colon was found to be generally infiltrated and bound down, so that it was impossible to bring any portion of it into the abdominal wound. An incision was made on the right side, but it was found that the whole colon was similarly infiltrated and fixed. The small intestine was normal, and enterotomy was performed. The whole colon was uniformly thickened, and the thickening terminated in a hard cartilaginous mass at the lower end of the sigmoid flexure. The colon was covered with pinkish- coloured nodules, looking like boiled sago. In J. W. Elliott's case,t the patient, a woman, had suffered from constipation and dyspepsia for twelve years. She was admitted into the hospital for a supposed tumour in the rectum. On opening the abdomen it was discovered that the whole colon * Trans. New York Surg. Soc. May 23, 1894. f New York Med. Rec. July 30, 1904. 214 TUBERCULOSIS OF from the rectum to the splenic flexure was a soHd tube so fixed that it could hardly be moved. A right-sided colotomy was performed, and a portion of the mass was removed for examina- tion. It was found to consist of simple inflammatory tissue. Tubercle bacilli were not looked for. Treatment. As already stated, the ulcerative form of tubercle of the colon usually occurs as a terminal complication in advanced phthisis, and there is little possibility of treating it, either by medical or surgical means. Occasionally it may happen that surgical treatment is called for to deal with some serious com- plication which has resulted from the ulceration, such as intractable diarrhoea, perforation with general peritonitis, and abscess. Colotomy can seldom be of any use in treating the diarrhoea, for the csecum is almost invariably involved. Appendi- costomy might be of value in controlling the diarrhoea, by enabling the colon to be washed out periodically, and it has the advantage that it is an operation of so little severity that it could easily be performed in cases where the patient is seriously ill with phthisis, without grave risk. I do not, however, know of any case in which it has been done. The Treatment of Hyperplastic Tuberculosis of the Colon. — This condition is so rare and so little known, that it is very seldom a correct diagnosis is made previous to operation. The abdomen is generally opened to relieve obstruction, or to explore a tumour, supposed to be malignant. Even when the tumour is seen, it is still usually thought to be malignant ; and, indeed the diagnosis cannot be made without cutting open the tumour, or microscoping a portion of it. This being the case, the treatment adopted is almost invariably that for cancer. It is therefore a fortunate circumstance that the best treatment for hyperplastic tuberculosis is the same, namely excision or short-circuiting. Unfortunately, however, with many patients the tumour is not excised, because the surgeon believes the condition to be one of malignant disease, inoperable because of adhesions and gland involvement ; whereas, did he know that it was tubercle, a successful excision might be performed. Operation is certainly the only cure for this form of tuberculosis of the colon, and medical treatment cannot be expected to do THE COLON 215 any good, though it may be useful after operation in preventing further tuberculous mischief. Of my collected series of 100 cases, all but 7 were operated upon, the methods of procedure being as follows : — Operation. No. OF Cases. Recovered. 47 13 I I Died. 16 3 2 Mortality PER CF.NT. Resection Short-circuiting Exclusion with colo- tomy Exclusion with lateral anastomosis 63 16 7 3 25-4 18-7 85 66 Totals 89 62 27 In addition to the above, exploratory laparotomy was per- formed in four instances. In some of the cases most complicated operations were done, live and even six being performed on the same case at different times. It will be seen that the lowest operation mortality was obtained by short-circuiting the tumour. This is, however, not so satis- factory as resection, as it leaves a source of infection behind. In several cases the tumour diminished in size, and in some it disappeared after it had been short-circuited. In four, however, a faecal fistula was left communicating with the tumour ; in two, the patient was only slightly improved by the operation ; and in another he died soon afterwards from phthisis. Short-circuiting is probably the best operation when resection of the tumour would be attended by considerable risk ; but these cases show that resection is a much preferable procedure. There are seven cases in which, after resection, the ends of the bowel were brought out. In four of these the patient had a permanent faecal fistula, which could not be closed in spite of secondary operations. Resection of the tumour is certainly the ideal method for this condition, and the operation-mortality is not much higher than that for short-circuiting. It is certain that this mortality of 25 per cent can be considerably lowered by not performing immediate resection and anastomosis where there is obstruction, or the bowel above the tumour cannot be emptied previous to operation. 2l6 TUBERCULOSIS OF The following table shows the methods adopted in dealing Avith the ends of the bowel after resection : — Cases. Deaths. Mortality PliR CENT. Immediate end-to end anastomosis . . 39 7 17 Closure of ends and lateral anastomosis or implantation . . Preliminary colotomy performed or ends brought out after i8 3 j6 excision , 9 3 33 One patient was well One One One Two patients were One patient was One One , , died of In three cases lateral anastomosis was performed first, and the tumour resected later. In twelve, where the stricture was resected, the subsequent history was traced for a year or more after operation :- 1 year later. 1 1 years later. 2 years later. 3 years later. 4 years later. 5 years later. ' 7 years later. general tuberculosis one year after operation, tuberculosis several years later, phthisis two years, and another three years after operation. One remained well for three years, then a fistula formed in the operation scar, and in an attempt to close it the patient died. When the tumour is in the sigmoid flexure, colotomy to relieve the obstruction and give rest to the tumour is certainly the correct treatment ; and later, if feasible, it can be excised Contra-indications to operation are : — 1. Extensive pulmonary tuberculosis, with high temperature. 2. Marked albuminuria. 3. Severe diarrhoea, showing the presence of extensive ulcera- tion. One One THE COLON 217 After operation, the patient should be put under medical treatment and carefully watched to prevent further tuberculous trouble, in the same way as w"0uld be done in a case of pulmonary tubercle. REFERENCES. F. S. KiDD. — Lancet, Jan. 5, 1907. Crowder. — Amer. Jour. Med. Sci. 1900, 638. CoNRATH. — Beitrage zur klin. Chir. 1898, 21. Reclus. — Bull. Med. 1893, 587. Page. — Lancet, 1897, ii. 10. Lediard. — Lancet, 1898, ii. 408. Bernay. — These Lyon, 1898. ROLLESTON. — Tvans. Path. Sac. 1S90. xl. 2l8 Chapter XV. CHROXIC coy ST IP AT lOX AXD F.ECAL IMPACTION. CHRONIC CONSTIPATION. Although it is usual to speak of chronic constipation as a disease, it is nevertheless onh- a s}TTiptom conunon to a great number of totalh" distinct and separate affections. Constipation results from the intestinal contents being unduly delayed in their passage along the aUmentary canal. This may occur in any part of it, but is most commonly found in the large bowel, and may result from a great variety- of causes. It is not possible in these da\-5 to consider constipation as a distinct maladj-, and the first essential alwa}^^ is to ascertain the cause for the condition. Chronic constipation, hke many other complaints of the present daj-, is in most cases a result of modem civilized Hfe. Among native races and wild animals it is practical!}^ unknown, but is all too common in civilized communities, and, indeed, forms one of the most frequent disorders of our great cities. Modem methods of dietary- and the sedentary character of our dailv Hfe are largely responsible for the tendenc\- to constipation which is so prevalent. It is one of the penalties we pay for the comparativelj^ small use we make of our colons. Dr. Hertz's recent researches, in which patients with severe constipation were examined by the X rays after a bismuth meal, have clearly proved that in most severe chronic cases the delav occurs in the lower part of the colon, and chiefly in the sigmoid flexure. This is the natural receptacle for the faeces previous to dejection. The rectum, being purely an expelling organ, is empty in normal individuals except just previous to and during the act of defsecation. Occasionally, constipation may result from the rectum not acting properly, as in chronic nerve lesions of the spinal cord, but this is com- paratively rare. Being only a sMnptom, constipation can have no distinctive; CHRONIC CONSTIPATION 219 pathology, and its causes form a large part of the subject matter of this book, and will be found scattered throughout its pages. It is obvious that there are two distinct kinds of constipation : 1. That in which the peristaltic power of the colon is normal, but the passage of faecal material is delayed by the presence of some obstruction in the bowel ; and 2. That in which there is no obstruction, but the peristaltic and expulsive power is deficient. The first is often called obstructive and the second atonic constipation. There is a third factor, which is often important, though it is not by itself a frequent cause of constipation. This is the consistency of the faecal material. The longer fscal material is delayed in its passage along the colon, the harder will it become, owing to the extraction of water by the bowel walls ; and the harder it becomes the less easily will it be passed along by peristalsis, so that a vicious circle is soon established. The consistency of the faeces, there- fore, is often an important factor both in obstructive and atonic constipation. An individual should not be considered as suffering from constipation simply because there is not an action of the bowels daily. Many persons only have such an action three or four times a week, and yet remain in perfect health ; while others again have a normal action twice daily. Constipation is only present when the bowels act with no regularity, or only as the result of aperients. Constipation is chiefly of importance because of the secondary symptoms to which it gives rise. These symptoms are very numerous, such as headache, dullness, discomfort in the abdomen, backache, furred tongue, etc., but the most important result of severe chronic constipation is the condition often called auto-intoxication. When the contents of the colon are unduly delayed in their passage to the anus, and remain long retained within the body, certain alterations take place. Chemical changes occur in the faecal material, and many of the waste products of digestion become still further spht up into poisonous substances or toxins. Under normal circumstances there would not be time for the formation of poisonous by-products before the faeces are discharged from the body ; but in chronic constipation considerable quantities of these may form while the faeces are still in the colon, and may then be absorbed by 220 CHRONIC CONSTIPATION the bowel-wall, and find their way into the blood-stream. The patient in fact is slowly poisoned by toxins formed within his own colon. We have good evidence of the extremely poisonous nature of these toxins in cases of intestinal obstruction. Here, when death occurs, it is more often due to a profound toxaemia from the poisons generated within the obstructed bowel, than from the obstruction itself. The toxsemia in chronic constipation is never so serious or profound as in intestinal obstruction, because the poisoning occurs more slowly, and the bowel-wall being undamaged, absorption does not occur so readily. It often, nevertheless, produces after a time very serious consequences. The patient becomes lethargic and listless. The appetite is poor, and there is a general feeling of not being well. The skin, instead of looking healthy, becomes of a greyish or earthy colour. The skin smeUs ; the tongue is coated ; and frequently much of the sub- cutaneous fat disappears. There is generally a chronic headache, and sometimes severe neuralgia and even more serious mental S5nnptoms have occurred. The appearance of patients suffering from chronic auto-intoxication is often quite characteristic, the listless appearance and the colour of the skin being alone sufficient to identify them as the subjects of chonic constipation. By no means all sufferers from constipation, however, are the subjects of auto-intoxication. We not infrequently meet with individuals whose bowels act most irregularly and at long inter- vals, without any apparent ill effects. I have seen at least two patients, whose bowels had not acted for three weeks or a month, who presented no signs of auto-intoxication, and we must assume here either that the poisons are not absorbed or that the patient is immune to their effects. Atonic constipation results from the muscular action of the bowel-wall being deficient. This is apparently not due to anj^ reduction in the number of the unstriped muscle fibres, but to the absence of the normal stimuH. Peristalsis is normally a reflex action set up by the presence of material within the bowel ; in atonic constipation this reflex becomes sluggish. Most often this constipation is a secondary condition resulting from irregular habits in going to stool, improper diet, viscero- ptosis, or some other general trouble. It may be associated with loss of tone in the abdominal muscles, and this becomes CHRONIC CONSTIPATION 221 important, since it is upon these muscles that the expulsion of the faeces chiefly depends. Among other causes of atonic constipation must be mentioned disease of the central nervous system, such as tabes dorsalis and disseminated sclerosis ; neurasthenia is often included, but it seems at least as probable that it is a result. Treatment. The treatment of chronic constipation obviously depends upon the conditions underlying it, and the correct method is to ascertain these causes and to correct or remove them. When due to obstruction, such as a chronic volvulus, adhesions, a tumour or stricture, operation is clearly indicated. For the treatment of obstructive constipation, the reader is referred to other portions of this book. In atonic constipation, treatment should be directed to improving the tone of the bowel-wall and increasing the normal stimulus to peristalsis. For this purpose a course of massage, combined, if possible, with suitable electrical treatment, is usually most efficacious if properly carried out. Strychnine or nux vomica are most useful in increasing the peristaltic movements, and their action is often enhanced by the addition of belladonna. At first these drugs should be combined with a small amount of some mild aperient, and later, when they have begun to do good, should be used alone. I have found the following pill most useful in these cases : — B Ext. Colocynth. co. . . . . . . grs. ix Ext. Cascarse . . . . . . grs. x Ext. Belladonnae . . . . . . grs. iv Ext. Nucis Vomicae . . . . . . grs. iv Mitte pil. xii. — One or two at bedtime each night. The results of treatment in cases of chronic constipation are far better where aperients are not used. They are an easy means of getting the bowels to act ; but they do not remove the cause of the condition, and, as a rule, ultimately result in making it worse, or in the patient being condemned to continue their use. Occasionally, where there is a gouty element, the use of some aperient water containing small doses of magnesia and lithia 222 CHRONIC CONSTIPATION is very beneficial, but with a few exceptions aperients are best avoided. Enemata are in many cases much to be preferred to the use of aperients, and especially where for long periods some artificial aid has to be used to ensure the bowels acting. There are frequent instances where the abnormal solidity of the fseces is a most important factor in maintaining the condition ; here it will be found that if steps are taken to prevent the faeces from becoming solid a marked improvement will quickly result. In a few cases merely increasing the amount of fluids drunk during the day will be sufficient ; but as water is readily absorbed by the colon wall this will only be of service where the patient has been in the habit of taking less fluid than his tissues require, and in whom, therefore, the deficiency has been made up from the faeces. Fats, which are liquid at body temperature, will prevent the faeces from solidifying, and as only a very limited quantity of fat can be absorbed by the alimentary tract, it is quite easy to attain the desired result by giving an excess of fat in the diet. The addition per diem of two ounces of thick cream to the patient's diet will generally render the stools quite soft, and it is easy to ascertain by experiment the exact quantity of fat required. Salads with oil, milk, bacon, and other forms of diet which contain fat, will readily suggest themselves. Some patients, however, are unable to take an excess of fat without getting dyspepsia. Mineral fats have not this objection ; they are not absorbed at all in their passage through the ahmentary canal, but pass out as they went in. Petroleum in some form can be given for any length of time without causing harmful results, and by administering suitable quantities of it any desirable consistency of the faeces can be obtained. Several different forms of emulsion containing petroleum have recently been placed on the market, and have been much lauded in the treatment of constipation and allied conditions, but emulsions are not so efficacious as pure petroleum, and their only advantage is that they are slightly less greasy to the taste. Lenital is the best preparation, and should be given by the mouth in teaspoonful doses. As a rule a teaspoonful of Lenital three times a day will very quickly render the stools quite soft or even semi-liquid. If not, the CHRONIC CONSTIPATION 223 dose should be increased until this result is obtained. It is rather greasy, but otherwise tasteless except for a ilavouring of peppermint, and I have found that patients do not object to it or find it unpleasant to take. I have had a number of cases of severe chronic constipation of the atonic type which have entirely recovered by the employment of this simple remedy alone. Even some cases of obstructive constipation are very much improved by rendering the faeces soft, and as an adjunct to massage and electricity it is most useful in cases of constipation due to adhesions. I have had several patients who for years had been in the habit of taking aperients daily, and whose bowels only acted as a result of medicine, who have been able entirely to stop the use of aperients when they began to take petroleum in this form. Massage. — This is one of the best methods of treating atonic constipation, and cases where there are adhesions interfering with the movements of the bowel. It is also useful after operations undertaken for the cure of obstructive constipation. For the success of this treatment it is essential that a skilled masseur or masseuse be employed ; partially trained persons are of little use. Before commencing the massage the patient should be put on a fuU diet containing plenty of cellulose and a sufficient quantity of fat, or its substitute petroleum, to ensure the faeces being unformed. If possible, it is better to commence with massage for ten minutes twice a day about two or three hours after meals. This is very much better than one treatment of longer duration, and is more easily borne by the patient. The massage must at first be very gentle, and only slowly increased as the patient becomes accustomed to it. Very vigorous massage is a mistake, and does far less good than hght massage. We should aim at moving on the contents of the colon by stimulating peristalsis and by direct kneading of the colon in a direction towards the anus. Special attention should also be paid to the development of the abdominal muscles, and for this purpose the exercises described below are most useful, and may with advantage be combined with the massage. After a few days, if the massage is well borne and does not cause discomfort, each treatment may slowly increased up to twenty minutes twice daily. There is little to be gained by continuing it for more than twenty minutes at one time. As soon as massage is commenced, 224 CHRONIC CONSTIPATION all aperients should be stopped, if they are being taken. Usually the bowels at once commence to act naturally ; should they not do so, enemata of soft soap and water should be used. The massage should be continued daily for at least three weeks, and if possible longer ; after this, for two or three times a week for another six weeks or two months. Patients often object to the inconvenience of daily massage ; but I have found it most important, unless only temporary benefit is to result from the treatment. When the patient has sufficiently improved as the result of the treatment, and the bowels are acting regularly, he should be told to take daily exercise, preferably walking or riding ; and to make a habit of relieving the bov/els at the same time each day. Cannon balls covered with wash-leather, and various forms of rollers, are often used in the treatment of constipation by massage, but if a skilled masseur is obtainable artificial aids are unnecessary. Vibration, if proper apparatus is used, is also a useful aid to massage in these cases. Exercises for Developing the Abdominal Muscles. — The following exercises should be carried out daily, at first under the supervision of the masseur, and later by the patient for himself. They should be done in succession, and continued about fifteen minutes, but never for long enough to cause fatigue. Each movement should be done slowly and deliberately. When the patient is also having massage, it should follow the exercises. Exercise i. — The patient should lie flat on his back on a firm bed or upon the floor, and with his hands by his sides. The knees should be drawn up to the chest, then straightened out at right angles with the trunk. With the knees kept stiff, the legs should then be slowly lowered until they again touch the bed. Exercise 2. — With the patient lying as before, the right leg, with the knee kept stiff, should be slowly raised till it is at right angles with the body. It should then be slowly lowered again, still with the knee stiff, stopping for a few seconds at different angles with the trunk. Two or three stops should be made before the leg again rests op the bed. The same exercise should be carried out with the left leg. Exercise 3. — The patient should lie on the floor with his hands by his sides. Then, while his legs are held down, he should slowly raise himself into a sitting position without using his hands. CHRONIC CONSTIPATION 225 The body should then be twisted round, first in one direction and then in the other ; he should then slowly lie down again. Exercise 4. — The patient stands up and slowly raises first one leg and then the other. Each knee should be brought up until it touches the chest. Exercise 5. — The patient stands with his hands on bis hips and slowly rotates the body, first in one direction and then in the other. Exercise 6. — Repeat Exercise 2, but with both feet together instead of alternately. This and Exercise 7 should not be used at first, but may usefully supplement the foregoing exercises at the end of a week or ten days. Exercise 7. — The patient sits on the floor, and the feet are held down. He then slowly sways himself backwards and forwards from the hips. Exercise 8. — (This is to develop the gluteal muscles). With the hands on the hips, the patient squats down on his heels ; then slowly raises himself into the standing position, and again slowly lowers himself until he is sitting on his heels. This should be repeated two or three times. Electrical Treatment. — ^There are many different kinds of electrical treatment used for chronic constipation ; some are quite useless, as they do not cause contraction of the unstriped muscle of the bowel-wall. This especially appHes to small galvanic and faradic apparatus which can be obtained for a few^ pounds ; such apparatus are quite valueless for this purpose, and if benefit does occur after their use, it is due to suggestion rather than to electricity. One of the forms which seems to do most good in atonic cases is the application to the abdomen of a continuous current with quick reversals, one reversal each minute. The pads should be large, and applied one on each side of the abdomen. A cushion must be placed between the knees to prevent their knocking together and becoming bruised. The current should go up to 100 milhamperes. Each treatment should last about ten minutes, and not be repeated oftener than thrice a week. Another very useful form of electricity is the three-phase sinusoidal current. The patient lies on a couch with one large pad in the middle of the back, and two smaller ones, one on each side of the abdomen. The current should not be strong enough to cause any discomfort. The treatment should be continued for about fifteen or twenty minutes, care being taken to switch 15 226 CHRONIC CONSTIPATION off the current before putting on or removing the pads, and not to disturb the pads while the current is passing. The high-frequency current is also useful if properly applied. A good apparatus is essential, and a very high frequency current should be used, with a spark-gap of not less than one and a half inches. The patient should lie on a couch which is not insulated, and should be in good contact with the electrode ; that is to say, he should either firmly grasp a metal bar electrode, or have one resting firmly on the abdomen. The administration of the high-frequenc3;' current by means of loose and moving contacts, such as brushes or glass electrodes which are moved about, causes pain, and serves, I believe, no good purpose. The current should alwa3^s be switched on after the patient is in contact with the electrode, and off before he has released it. If properly administered it should cause no sensation while pass- ing. It should be administered every day for fifteen minutes. Hydrotherapy in its various forms is now very popular for the treatment of chronic constipation, especially at the English and Continental spas. Personally, I have not seen as good results from it as from massage and electricity. The so-called Plombieres treatment, or lavage of the bowel, is not suitable in atonic constipation, as it dilates an already weakened and dilated colon, and, I believe, tends to increase and accentuate the atony of the bowxl-wall rather than to improve it. It undoubtedly does temporary.' good b\' clearing out the colon and washing away scybala, but the improvement is seldom permanent, while some cases are certainly rendered worse b}.' it. Plombieres treatment consists of the daily adminis- tration of large enemata, containing a slight quantity of some salt, by means of a long tube. It is supposed that the long tube passes into the colon, but, as I have already pointed out, this is not the case ; the tube in most cases remains curled up in the rectum. Any good results obtainable from Plombieres treatment can be equally realized by the use of ordinary soap and water enemata when properly administered. ^ Operative Treatment. — Operations which are performed for chronic constipation without reference to the underlying pathological cause cannot be considered as satisfactory or scientific procedures ; before advising operation there should be a clear understanding of the pathological conditions at work, and the manner in which they are to be benefited. CHRONIC CONSTIPATION 227 In most cases of obstructive constipation, surgery affords the only satisfactory means of dealing with it or of curing it. The various methods employed will be found elsewhere in this book. There are certain cases of atonic constipation in which operation is called for ; but these are exceptional, and in all of them, if a thorough course of non-operative treatment has not already been tried, it should first be prescribed. The cases which require operation are those in which the patient is getting seriously ill from auto-intoxication, and the bowels cannot be made to act regularly either by enemata, aperients, or massage. Cases are occasionally met with in which nothing seems to do good, and patient and doctor are in despair. The patient has spent months at spas without any permanent relief ; massage only causes discomfort, and only the most drastic aperients, and those in full doses, will relieve the bowels. The patient is always ill, and can think of nothing else but the condition of the bowels, and is rapidly becoming a chronic invalid. Here an operation is certainly the best treatment, and is quite justified. Three methods have been advised, viz. : — 1. To perform appendicosiomv , in order that the colon may be washed out daily, and the accumulation of faecal material within it thereby prevented. 2. To short-circuit the colcn by performing ileo-sigmoidostomy. 3. To resect the entire colon. Appendicostomy. — It is obvious that it is not the colon which causes auto-intoxication so much as the material which is retained in it. If we can prevent this retention, we shall be able to stop the chronic poisoning from which the patient suffers. If an appendicostomy is performed, the patient is able to wash out the colon daily and so prevent accumulation. The results have in most cases been extremely encouraging, and the daily irrigation has caused rapid and marked improve- ment in the patient's general condition. Further, in several cases after irrigation has been carried out continuously for some time, there have been signs that the colon was recovering its lost functions, the bowels having begun to act regularly without the irrigation. Appendicostomy has an advantage over the other two operations mentioned, in that it is practically un- attended by any risk to life, and that it does not in any way 228 CHRONIC CONSTIPATION mutilate the patient or leave a condition which may at some later period cause trouble. Ileo-sigmoidostomY. — In October, 1900, Mr. Mansell MouUin published a case in which he had performed this operation for chronic constipation, and Mr. Arbuthnot Lane published a paper advocating it in 1904. Mr. Lane, who has performed a number of these operations, found that the results were satisfactory, but that the partially excluded colon was a source of danger, and this has led him to advocate complete resection of the colon as being preferable. Resection of the Colon. — This has been often performed by Mr. Lane, the ileum being implanted into the rectum or sigmoid flexure. Frequently a very marked improvement in the patient's general condition resulted from the removal of the colon. The operation is, however, a severe one, and the improvement is not always permanent. Lane has reported 28 cases of excision of the colon for this condition ; of these 7 died and 21 recovered. This is a mortality of 33 per cent. Sufficient time has not yet elapsed to enable us to determine the ultimate results. The mortality in Lane's cases is sur- prisingly low for so serious an operation ; but it seems very doubtful whether a method followed by so high a mortality as 33 per cent is justifiable, especially when appendicostomy seems to be attended with equally good results in similar cases. It is certainly advisable to do appendicostomy first, and only resort to resection if this fails to relieve the symptoms. F^CAL IMPACTION. Occasionally a fsecal mass or enterolith forms in the colon, and causes a condition of chronic, or in a few cases even acute, obstruction. The commonest situation for such fascal masses is in the rectal ampulla, but they may also be met with in the caecum, the sigmoid flexure, and at the splenic angle. Out of the 46 cases collected by Gant, the situation of the calculus or mass was as follows : — Cases. Rectum . . . . . . 35 Sigmoid ... . . . . 5 Descending Colon . . . . i Transverse Colon Caecum F^GAL IMPACTION 229 They are not infrequently met with in the rectum of old women the subjects of chronic constipation. Under such circumstances thej^ are about the size of an orange and of the consistency of concrete. Fffical calculi are most frequently met with in elderly persons, but are not confined to an^- particular age, and may be found even in children. The concretion is usually single, but cases of multiple calcuH have been recorded in which as many as 38 were removed from the same patient. The composition varies considerably. They may consist of anv indigestible material which has been swallowed, such as hair, cotton fibre, and cellulose. The majority, however, are composed of a mixture of inspissated faeces and inorganic salts. The nucleus is generally a foreign body, such as a fruit- stone. The chemical composition of these stercoliths, apart from the foreign bodies of which they may be composed, is variable ; but the usual ingredients include magnesium and ammonium phosphate, potassium sulphate, sodium carbonate, calcium phosphate, and cholesterin. The centre is usually very hard, and white or colourless. Outside this are concentric layers of earthy matter of varying degrees of hardness. These calcuU are often of considerable size. I have removed one from the rectum which was the size of a child's head. Faecal impaction and the formation of enteroliths is never a primary condition ; some abnormality of the colon or rectum, of the nature of obstruction or atony, must necessarily be present. The most distinctive cases of faecal impaction, in which the mass often weighs several pounds, are those curious instances of congenital dilatation and hypertrophy of the colon. (See Chap. IV.). Fffical calculi tend to set up inflammation in the surrounding colon, and many of the symptoms they cause are due to this fact. Ulceration, and in a few instances perforation, may occur. The following rare case, in which a faecal calculus was found in the splenic flexure, producing obstruction, w^as recorded by M. Morestin. Case. — The patient was a woman, aged 31, who had suffered from constipation for two years. Abdominal pains set in during gestation, and a month after delivery a tumour was felt in the 230 FvECAL IMPACTION abdomen. The patient became ill, with symptoms of chronic obstruction, which were only temporarily relieved by enemata. On opening the abdomen a fa?cal calculus of extreme hardness was found in the splenic angle of the colon. This portion of the bowel was resected, together with the calculus, and the colon anastomosed end to end. The patient recovered. The stone required a hammer to break it, and consisted of concentric laminae. It measured 7 inches in its longest by 5! inches in its shortest diameter, and weighed 368 grams, about four-fifths of a pound. There was a stricture from old ulceration at the site where the concretion was impacted. Case. — A case was recorded by M. Pozzi at the French Congress of Surgery in October, igo8, of a man who for years had suffered from an abdominal tumour of absolutely wooden consistency. It extended from the umbilicus to the pelvis, and was movable only in a transverse direction. No exact diagnosis had been made. M. Pozzi performed laparotomy, and found that the tumour con- sisted of the lower part of the sigmoid flexure, in which was a stercolith of stony hardness. The intestine was divided and the mass removed. The gut was subsequently closed, and the patient made a good recovery. A similar case is recorded by Balfour Marshall.* : — Case. — The patient was a woman, aged 46, who complained of a small lump in the abdomen, to which she attributed her sym- ptoms. The chief complaint was of colicky pains. There was a history of constipation. In the lower right quadrant of the abdomen there was a hard ovoid lump, the size of a hen's egg. It was freely movable. It was thought to be either a solid ovarian tumour with a long pedicle, or cancer of the bowel-wall. Laparotomy was performed, and the tumour was found to be a stercolith in the caecum above a fibrous stricture. The stricture and c^cum were incised and the mass removed. In sewing up the wound in the caecum the stitches were so inserted as to render the wound transverse instead of longitudinal, thereby increasing the diameter of the strictured area. Recovery was uninterrupted. Symptoms. The characteristic sjmiptoms of fgecal calculi are diarrhoea and colic. This not infrequently leads to a wrong diagnosis, as it is sometimes supposed that constipation should result from a faecal impaction in the colon. The diarrhoea is spurious, * Glasg. Med. Jour. 1907, 238. Fy^GAL IMPACTION 231 and is due to the irritation and ulceration set up by the cal- culus. If the concretion is in the rectum, tenesmus is a prominent feature. After a time blood and pus may make their appearance in the stools. The stools themselves are thin, watery, and frequent, but small in quantity. The symptoms in fact are those of ulcerative colitis rather than anything else. In faecal impaction not due to a calculus, ulceration is less common, and constipation is the rule, accompanied by abdominal colic and sometimes vomiting. A careful examination both of the rectum and abdomen will generally clear up the diagnosis, as the mass can be felt. If it can be indented the diagnosis is clear, but where a hard calculus is present in som^e part of the colon where it cannot be seen by the sigmoidoscope, it may be difficult to distinguish the condition from cancer. Treatment. When the condition can be diagnosed, attempts should be made to soften the mass by means of large oil enemata, and if this succeeds the mass can be slowly washed out by repeated soap-and-water enemata. A solution of hydrogen peroxide, if it can be brought into contact with a feecal concretion,, will readily split it up and disintegrate it. As the peroxide soaks into the mass, bubbles of gas form in its substance and break it up. X^'hilc this is a very effective method, it is not free from risk, as the large quantity of gas formed distends the bowel and may rupture it, especially if there is any ulceration. If a free exit lor the gas can be ensured, however, this method of breaking up the calculus may be tried. As a rule, when the calculus is in the colon, surgical operation affords the onl}- possible means of dealing v.'ith it. The abdomen should be opened and the portion of the colon containing the calculus brought into the wound. If possible, the calculus should be pressed up into a healthy portion of colon. This should then be incised in the long axis, and the calculus removed. Before closing the incision into the bowel the interior should be examined for a stricture, which is frequently present, and if this is found it should be dealt with at the same time. It is well to remember that faecal impaction, or the formation of a calculus, does not occur in a normal colon, and that the presence of one of these conditions indicates some abnormalitv 232 F^GAL IMPACTION of the bowel. The following case well exemplifies this state- ment. Case. — The patient was an elderly gentleman who for some months had been troubled with constipation, to which he was not accustomed. On examination of the abdomen, his doctor discovered a tumour in the left iliac fossa, and asked me to see the patient with a view to ascertaining its nature. Before I saw him a dose of castor oil and several enemata had been administered, and as a result the tumour had disappeared. An attempt to examine him w-ith the sigmoidoscope failed, as the bowel was still loaded with fseces. We came to the conclusion that the tumour had been a fsecal mass, but that a further examination after the bowel had been emptied was advisable to ascertain the cause of the accumulation. To this, however, he would not agree, as he considered himself cured. A year later this patient had an attack of acute obstruction, and colotomy was performed. It was then discovered that there was a cancer of the sigmoid flexure, which had doubtless been present before, and could have been detected had he submitted to be examined properly. 233 Chapter XVI. SIMPLE STRICTURE OF THE COLON AND EMBOLISM OF THE MESOCOLIC VESSELS. SIMPLE STRICTURE. Compared with malignant stricture this is a rare condition. Cases of simple (non-malignant) stricture may be divided into three kinds : — 1. Stricture due to hyperplastic tuberculosis. 2. Stricture due to pericolitis. 3. Cicatricial strictures the result of ulceration. The first two conditions are commonly mistaken for cancer, and so close is the resemblance that it is often only possible to be certain of their benign nature after careful microscopical •examination. Both in hyperplastic tuberculosis and pericolitis the stricture is accompanied by considerable tumour formation. These conditions will, however, not be further considered here, as they have already been described in Chapters XIII. and XIV. Cicatricial stricture of the colon is a very rare condition. Out of 669 cases of intestinal obstruction collected by the late H. L. Barnard from the records of the London Hospital, there were only four of simple stricture of the colon, and these were all in the sigmoid flexure. Simple stricture of the colon, as also of the rectum, has been supposed to be a result of tertiary syphilis ; but after careful search, I have not succeeded in finding a single instance of ■an undoubted syphilitic lesion, much less of a syphilitic stricture. It may be congenital, and in Chapter VI. several such cases are given. The commonest cause is undoubtedly the contraction following severe chronic ulceration. As I have already pointed out, most ulcers of the colon heal, if at all, without leaving much scarring. If the ulcer is very large, however, and has entirely 234 SIMPLE STRICTURE destroyed the mucous membrane, scarring and contraction may result. This is especially the case v/ith chronic ulcers.* I have seen one case of a diaphragm- Hke stricture of the pelvic colon in which the condition appeared to have resulted from previous ulceration. In St. Bartholomew's Hospital museum there is a very interesting specimen (see Fig. 58) of a cicatricial stricture in the middle of the transverse colon. There are a number of curious thread-like polypi hanging from the mucous membrane in the neighbourhood of the stricture. Curiously enough, dysenteric ulceration apparently never results in stricture. Thus, out of the records of 287,522 cases of dysentery occurring among the troops in the American Civil War, there was no single instance of a stricture of the colon. A very moderate degree of stricture in the descending or pelvic portions of the colon will cause obstruction, owing to the solid nature of the contents. When acute obstruction occurs from a simple stricture, the actual cause of the blockage is always faecal impaction. Most of these cicatricial strictures are complicated by the presence of adhesions around the bowel which, like the stricture, have resulted from the previous ulceration. The changes which occur in the bowel above the stricture are those usually associated with a chronic partial obstruction. The bowel is dilated and its walls are markedly hypertrophied. Stercoral ulceration may be present, and in some cases multiple polypi have been found growing from the mucous membrane just above the stricture. The formation of stercoliths thus situated has already been referred to in Chapter XV. Treatment. The condition may be treated either by resection of the affected * The following case is recorded by Quenu and Duval {Rev. de Chivurgie, Dec. 10, 1902). The patient was a man, age 67. For some time he had complained of pain in the abdomen, and sufiered from habitual constipation. His bowels were for long periods unrelieved. Examination of the abdomen revealed a hard cylindrical mass in the csecal region. Nothing could be felt per rectum, and intestinal obstruction probably due to cancer was diagnosed. The patient refused to be operated upon, and died. Post mortem, a large abscess cavity, shut off by adhesions, was discovered in the lower part of the abdomen. This cavity communicated with the sigmoid flexure by a perforation at the bottom of an old ulcer. The contraction of the ulcer had caused an. annular constriction which almost occluded the bowel. OF THE COLON 235 portion of bowel, or by incising the bowel-wall over and through the stricture, and then sewing up the resulting wound in a transverse direction. The operation is, however, often much complicated by the presence of adhesions in the neighbourhood, and it may sometimes be better to deal with the case by short- circuiting the affected portion of bowel by lateral anastamosis. THROMBOSIS OR EMBOLISM OF THE COLIC BLOOD-VESSELS. Embolism of one of the main arteries of the colon, or thrombosis of the veins, results in complete obstruction. The contents of the colon are arrested and the bowel above becomes distended. Thrombosis is a very rare condition, and is but seldom diagnosed during life. The symptoms produced by embolism or thrombosis are those of intestinal obstruction, and it is not possible to make a correct diagnosis unless there is some reason to expect embolism. Exactly why an infarcted portion of the colon should produce obstruction it is not easy to see ; but it apparently acts as a complete block to the passage of the intestinal contents, and the bowel above becomes dilated as if a stricture were present. When seen, the appearance of the bowel is characteristic. It is of a dark chocolate colour, and in marked contrast to the surrounding healthy bowel. When laid open, the mucous membrane is seen to be purplish in colour and oedematous. For the notes of the following case, which well illustrate this rare and interesting condition, I am indebted to Mr. Littlewood, of Leeds. The patient was a woman, aged 64. She was much wasted. There was a history of several days' complete intestinal obstruc- tion, with faecal vomiting and some abdominal distention. There was no history of mel£ena, and no evidence on examination of any cardiac lesion. An exploratory laparotomy was performed. The patient was very ill, and died on the operating-table. A post-mortem examina- tion revealed in the left half of the transverse colon a portion about 2| to 3 inches in length which was thickened and oedema- tous. The corresponding portion of mesocolon was similarly thickened, and both this and the bowel-wall were markedly injected. On opening the gut, the mucous membrane was seen to be of a chocolate colour, and slightly swollen. The affected 236 EMBOLISM OF COLIC BLOOD-VESSELS portion of mucous membrane was, owing to the change in colour, sharply marked off from the normal mucosa. There was well-marked venous dilatation. Thrombosis was discovered. One small artery near the bowel contained blood-clot, but the clot was not apparently attached to the vessel wall. The colon was distended, and the discoloured portion of the transverse colon marked the junction between the distended and collapsed portions of bowel. The caecum was greatly distended, and there was distention of the ascending and right half of the transverse colon ; but the distention termi- nated at the discoloured portion of bowel, and the descending colon was collapsed. The remainder of the intestine was quite normal, as were also the other abdominal organs. Treatment. When an extensive area of colon is involved, it is unlikely that any operative or other treatment will avail. But if the infarcted area is not large, and operation is performed early, resection of the whole damaged area of bowel will probably save the patient's life. It is unhkely that the condition will be diagnosed previous to operation ; but as the symptoms are those of intestinal obstruc- tion, a condition calhng for immediate operative interference, this is not a serious obstacle to a successful result. 237 Chapter XVII. SIMPLE TUMOURS OF THE COLON. Simple tumours are not very common in the colon. Fibrous tumours, the result of diverticula and pericolitis, and hyper- plastic tuberculosis, are sometimes found, and have already been referred to under these headings. These fibrous tumours, however, are inflammatory in origin, and not true tumours. Lipomata are occasionally found in connection with the colon ; but they are rare, and seldom cause symptoms unless of very large size. Mr. Bland-Sutton, in his book on tumours, relates a case in which he removed a lipoma of the ascending colon which was causing obstruction. Villous adenomata occur in the colon ; but they are seldom detected before they have become mahgnant. In most cases, when removed, they are found to show well-marked malignant changes, and are therefore usually classified as malignant tumours. Single polypi are occasionally met with, and are a well-known cause of intussusception ; their structure is usually adenomatous, and they have a long pedicle produced by the action of peristalsis in attempting to move them along the bowel lumen. Multiple Polypi of the Colon. — One of the most interesting and curious forms of simple tumour of the colon is the condition described as multiple polypi. It is also described as multiple adenomata and colitis polyposa. The condition is rare ; but I have been able to collect a number of cases ; and several drawings and photographs of the condition are appended. " Multiple polypi of the colon " is not a pathological entity, but includes several distinct diseases which have been described under this name. Multiple polypi may be divided into four classes, as follows : — (i) True multiple adenomata ; (2) Polypi found in association with hyperplastic tuberculosis ; (3) Multiple polypi 238 SIMPLE TUMOURS found in association with an old stricture of the colon ; (4) The polypoid condition of the mucosa which sometimes results from ulcerative colitis. ^'S- 53- — Multiple adenorr.ata. (.)/;-. Frcd'c. WalUs's case. Charing Cross Hospital Museum.) I. True Multiple Adenomata. — This is a curious condition in which there are numbers of small adenomata growing from the mucous membrane of the colon. It was first described by Virchow in a paper written in 1863. OF THE COLON 239 The number and size of the polypi vary considerably in different cases. They may be quite small and very numerous, so numerous in fact that the entire colon is covered with them, or they may be large and comparatively limited in number. There appear to be two distinct types : one in which the entire colon is covered with small semi-pedunculated polyps in such \ •> fi^-i 7v>. 54. — Multiple polypi of the colon (Charing Cross Hospital Museum}. numbers that the mucosa is almost hidden. The two best- marked cases of this tj^e are : — Mr. F. Wallis's case, the specimen of which is in Charing Cross Hospital (see Fig. 53), and Lienthall's case. In the former there was a similar condition in che stomach, and in part of the small intestine, and the condition 240 SIMPLE TUMOURS resembled lymphadenoma. In Lienthall's case the disease was apparently confined to the colon. This type is extremely rare. In the other and commoner class there are numerous polypi of all sizes and shapes, some of them sessile, but the majority pedunculated. The sessile polypi appear to be but the early condition of the large pedunculated ones. They are often large, and may have pedicles an inch or more in length. In one ^^H^^ i ■•,-■ ■j/v^''^ ^ ^ B^r-r. ^ ■^'£- 55.— Multiple polypi of the color, associated with a cancerous stricture. (From a specimen in the Great Northern Hospital Museum.) of my cases a polypus which broke off and was passed per anum was as large as a walnut, and had a long narrow, ribbon- like stem. There may be great numbers of these polypi distributed OF THE COLON 241 throughout the colon. There are usually numerous quite small and undeveloped potypi to be seen, and if these are examined the}^ are found to be growing from the free edges of the valvulse conniventes. An examination of several specimens makes it seem probable that the polypi all originate as outgrowths from the edges of these folds. (See Fig. 57.) They are, as a rule, most numerous in the pelvic and descending portions of the colon. The rectum is also commonly affected. The pol^'pi in the rectum are naturally the most easily detected, and in several instances the condition is described as multiple polypi of the rectum. But I have found no case in which the condition was confined to the rectum ; careful investigation or post-mortem examination always proves the colon also to be affected, while in some the rectum is not affected at all. The condition is always accompanied by a certain amount of inflammation of the mucous membrane, and gives rise to severe and intractable diarrhoea and haemorrhage. The Microscopical Appearances. — When sections are examined under the microscope these poK^i can be seen to consist of a central mass of typical adenoid tissue, covered outside with the ordinary columnar-celled epithelium of the colon. They are not, however, simple outgrowths or excres- cences of the mucous membrane, as the submucous coat is represented. A careful microscopical examination shows that they originate beneath the mucous membrane, probably in the solitary follicles, and, as they protrude into the bowel, become covered and surrounded by the mucous membrane. In the pedunculated variety there is, as a rule, no adenoid tissue in the pedicle, which consists of a tube of mucous membrane enclosing connective tissue continuous with the submucous layer of the bowel-wall. Little is known as to the etiology of these polypi. The condi- tion occurs at all ages and about equally in the two sexes. The most probable explanation is that they arise from irritation. I recently saw a case in which the condition occurred in a child of four as the result of worms. The fact, already mentioned, that there are almost invariably chronic inflammatorv changes in the mucous membrane, supports the same view, v/hich is further strengthened by pohrpi being often found associated with simple stricture of the colon and v/ith hyperplastic tuberculosis. Secondary Changes in the Polypi. — The larger poljrpi, 16 242 SIMPLE TUMOURS especially those near the lower end of the pelvic colon, tend to become ulcerated from the traumatism to which they are sub- jected by the passage of the faeces. What is of much greater importance, however, is, that there is a marked tendenc v for some of the polypi to become malignant and cause an adeno-carcinomatous stricture. This is particularly liable to occur at those parts of the colon, such as the sigmoid /''/f. 56. — Multiple polypi of the colon with secondary cancer {Dlr. Gordon ll'a/so/i's case). flexure, where the polypi are most numerous and most subjected to traumatism from hard faecal material. In two of my cases there was already a cancerous stricture in the sigmoid flexure ; and in another there was evidence of cancer some months after the case was first seen. In this latter case numerous polvpi could be seen with the sigmoidoscope in the OF THE COLON 243 sigmoid flexure and the rectum. All the polypi in the rectum that could be reached were removed. One of these was examined, and showed the typical structure of simple adenoma. Some months later the patient developed symptoms of cancer in the sigmoid, but was too ill to return to the hospital. In one of the cases there was a carcinomatous stricture in the sigmoid, which was resected. On examination of the specimen it was evident that the growth had arisen in one of the polypi. Two of the pol3-pi at some distance from the growth were examined, and while one was a simple adenoma, the other showed signs of commencing malignancy. (See Fig. 56.) Out of the forty-two cases of multiple polypi of the rectum or colon collected by Ouenu and Landel, in twenty cancer was either present when the case was examined, or developed later. In one of my cases the patient was operated upon for cancer .of the sigmoid, and the bowel was resected. No polypi were seen in the resected portion ; but a year later he returned with .recurrence of symptoms, and on examination with the sigmoido- scope several pedunculated polypi were seen, some six inches above the old line of anastomosis. The patient died from a second operation, and, post mortem, there were some half-dozen .polypi, the highest of which was eight inches above the line of the original anastomosis. There was no recurrence at the original site ; but on examining several of the polypi, tw^o were found to be malignant. Symptoms. The most marked symptom is diarrhoea. This is severe and intractable. The patient rapidly wastes and becomes emaciated as the result of the constant loss of fluid, and there is not infrequently considerable tenesmus. The stools are Liquid and contain much slimy mucus. Blood is frequently present in the stools and is intimately mixed with them. The symptoms closely resemble those of cancer or ulceration of the colon ; but the diarrhoea is, as a rule, more severe. Abdominal pain is usually present, and in most of the cases there has been severe pain in the left side of the abdomen. There is, as stated before, often marked anaemia. There is usually a history of bleeding and diarrhoea for long periods. Thus, in one patient there had been almost continuous bleeding for ten years ; and in another the symptoms had 244 SIMPLE TUMOURS persisted without intermission for three. In one very remarl^c- able instance three members of a family suffered from the condition ; but I have been unable to find another similar case. An examination of the rectum usually reveals the presence of a number of polypi scattered over the mucous membrane, and the sigmoidoscope shows a similar condition in the pelvic colon. The colon is tender when palpated through the abdominal wall. The following are typical cases of the condition : — Author's Case. — A woman, aged 57. The patient was quite well until August, 1907, when she began to suffer from diarrhoea. This continued intermittently until October, when she began to notice blood in the stools, and had severe pain in the left side of the abdomen. These symptoms continued until her admission to hospital in January, 1908. At this time there were con- stant diarrhoea and much blood and mucus in the stools. On examination, there were numerous polypi in the rectum. The sigmoidoscope showed numerous polypi growing from the mucous membrane of the pelvic colon as far up as could be seen. They varied in size from quite small sessile polyps to peduncu- lated growths nearly as large as a walnut. At one spot there was some ulceration of one of the polyps, which suggested possible commencing malignant disease. Under an anaesthetic some of the polypi in the rectum were removed, and on examination showed a simple adenomatous structure. The patient left the hospital and returned home. When heard from in November she was still very ill, and there appeared to be symptoms of malignant stricture. In December, her doctor sent me a large polypus which had passed per anum ; on having sections of it cut, the typical structure of an adeno-carcinoma could be seen, so that there was no doubt malignant change had occurred. Case cf Multiple Polypi' of the Colon Associated with Cancerous Stricture cf the Sigmoid Flexure. — Specimen in St. Bartholomew's Hospital Museum (No. 2065). The patient was a man, aged 20, who died in the hospital. Ten years previously he was taken into the London Hospital for haemorrhage from the bowel, and was operated upon there. The bleeding returned in a few months ; and, at intervals, he had haemorrhage for the next four years. Several further operations were performed, and polypi removed ; but with only temporary rehef from the bleeding. A brother and sister of this patient were also under treatment at St. Bartholomew's, and were found on examination OF THE COLON 245 also to have multiple polypi of the bowel. On admission the patient was very anaemic, and complained of pain in the rectum. There was an almost constant discharge of blood and mucus from the bowel. On dilating his rectum under an anaesthetic numerous polypi could be seen in the rectum, and several of these were removed. He was re-admitted into the hospital n '^ ""^^M . '■'^ "''^S ^■ ' ^Mmi^^^^^BBiB ^™i^R V ''^^^ral^^^^^^^l ^^^' Hfe*(-3^<'* J m^a^ ^9^H^H[ 1 te ^^^■^^^^^^1 ■» "i?»-i?-- v'''4^ 57. — Multiple polypi of the colon. (Author's cast'.) three limes, on the last occasion with symptoms of peritonitis, from which he died. An examination of the specimen shows an adeno-carcinoma- tous growth at the recto-sigmoidal junction surrounding the bowel and almost obliterating it. Below the stricture there are numerous polypoid growths scattered over the bowel walls. There are also several above the stricture, and in the ascending 246 SIMPLE TUMOURS and transverse portions of the colon are three or four polypi. The colon above the stricture is enormously dilated, and the peritoneum over the anterior band has split from the distention. Most of the polypi are globular, with narrow pedicles, but "some are sessile or ribbon-like structures. The microscopical examina- tion shows the growth to be an adeno-carcinoma. The polypi are simple adenomata. A case* is reported by A. Samuels of a woman, aged 48, who for three-and-a-half years had suffered from frequent watery stools containing blood, and occasional vomiting. There was constant pain in the left side and considerable loss of weight. The abdomen was opened and the colon incised. Numerous polypi were found in the colon, and a large number were removed. The patient was better after operation ; but there were occasional recurrences during the next two years. Microscopically the polypi removed proved to be simple adenomata. 2. Polypi in Association with Hyperplastic Tuberculosis. ■ — These have already been described in dealing with tubercle of the colon. They occur in or just above the stricture. They may contain giant cells and tubercle bacilh. They may be present in considerable numbers and have long pedicles. 3. Polypi in Association with an old Stricture. — These polypi are verj/ curious. They are filiform structures, often of most curious and eccentric shapes, and several inches long. They are often looped or fork-shaped. They are in appear- ance quite unlike the polypi previously described ; and are only found in and just above and below an old simple stricture. (See Fig. 58.) They consist of connective tissue covered b3^ mucous membrane. - 4. Polypoid Condition Associated with Ulcerative Colitis- — These are not true polypi, though their appearance is very similar, but are the islands of mucous membrane left between the ulcerated areas. Each of these becomes partty undermined by the ulceration, and thus a pedicle is formed. The mucous membrane becomes swollen and hypertrophied, and in this way the appearance of a poH^us is produced. Treatment of Cases of Multiple Polypi of the Colon. Those forms of polypi accompanying tuberculosis and stricture * Surg. GyncBCol. and Obstet. 1509, p. 380. OF THE COLON 247 of the colon do not call for any treatment apart from the condi- tion with which they are associated. The treatment of multiple adenomata is a very difficult matter. In most cases the condition has only been detected in the rectum, and it has been supposed that the pol^'pi were confined to this part of the bowel, whereas they really extended more or less throu,?hout the large bowel. Most of the operations Fig. 58. — Drawing of a specimen in St. Dartholomew's Hospital Museum, showing a simple fibrous stricture in the centre of the transverse colon, and numerous filiform polypi growing from the mucous membrane above the stricture. The colon above the strictuie is dilated. performed have been confined to the removal of as many polypi as possible from the rectum, and in some cases forty or fifty have thus been removed. Such operations have, however, done no good, and the symptoms have persisted as before. In a few the anus and rectum have been laid open, to enable more polypi to be reached. Left inguinal colotomy has also been done with 248 SIMPLE TUMOURS OF THE COLON the object of deflecting the fsecal current ; but has been equally useless, because the opening was not above the disease. Cascostomy has also been performed. This was done in Lienthall's case, and the patient's symptoms were somewhat alleviated ; but no diminution in the size or number of the polypi resulted. None of these operations seem of the least use, and they should certainly not be performed. Colotomy does not relieve the sjnnptoms, and merely adds to the patient's distress. The disease is a very serious one. The patient suffers from severe and intractable diarrhoea and bleeding. There is often severe and distressing tenesmus, and rapid loss of weight and wasting. Moreover, there is every probability that cancer will develop, if it has not already done so. Under these circumstances any operation would seem justifi- able that affords a possibility of removing the disease. The only method that offers any reasonable prospect of deahng adequately with it is resection of the entire colon. This was done in Lienthall's case after a previous ileo-sigmoidostomy, and the patient recovered. This was probably the first instance in which resection of the entire colon was performed. Unfortunately, the rectum is usually affected together with the colon, so that the whole of the disease cannot be removed ; but if the anastomosis is made low down, the polypi in the rectum could in most cases be removed later ; and, at any rate, this operation seems to be the only one at all worth considering. Resection of a cancer of the colon which is found to be associ- ated with multiple polypi is apparently not worth doing unless the rest of the colon is either removed at the same time or subsequently. The evidence available seems to show that cancer will recur in some other part of the colon if it has not already done so. 249 Chapter XVIII. MALIGNANT DISEASE OF THE COLON. The commonest form of malignant disease met with in the colon is adeno-carcinoma. Cancer of the colon is a comparatively common disease ; indeed, of all the different diseases to which the colon is liable, cancer is probably one of the commonest. Neither is it confined to the later periods of life, for it appears often to affect the colon at an earlier age than with many other parts of the body. Out of loo cases collected from various sources, I found that eleven were under 30 years of age, and four under 20. The youngest patient was a child, age 5, and another was only 12 years old. Mr. Mayo Robson also records the case of a child aged 14 with cancer of the colon. The two sexes seem to be about equally affected. In my series 55 patients were males and 45 females. Situation of the Growth. — The following four series of cases show the comparative frequency of cancer in different portions of the colon : — Situation London i Clogg's Hospital. Series. Tuttle's Series. Lichtenstf.in's Serces. Caecum . . Ascending Colon Hepatic Flexure Transverse Colon Splenic Flexure . Descending Colon Sigmoid Flexure 41 6 3 17 12 6 103 17 5 3 10 o7 I r 283 '- 160 32 6 1 ■= 1 1 42 Total 188 72 625 121 It will thus be seen that the sigmoid flexure is the commonest situation ; next the caecum and ascending colon ; then the transverse colon or splenic flexure. The parts least commonly affected are the hepatic flexure and the descending colon. The 250 MALIGNANT DISEASE dependent parts of the colon are those most commonly affected with cancer, namely the caecum, middle of the transverse colon, and the sigmoid flexure. It is in these regions of the bowel that stagnation of the contents tends to occur most frequently. Predisposing Causes of Cancer of the Colon. — Of the real causes of cancer of the colon, or elsewhere, we at present know nothing, and the predisposing causes are chiefly of import- ance in that they may help us in forming an opinion as to the prognosis in cases in which we know that such causes exist, and in determining, whether or no an operation should be under- taken to remove some lesion which may later become a site of cancer. Prof. Nothnagel has stated that cancer of the bowel not infrequently arises at the site of an ulcer of simple origin in the mucous membrane. That a congenital abnormality of the colon may be a predispos- ing cause seems probable. A case is recorded by Lockwood, in which the descending colon was double, and at the site of junction of the two tubes there was a cancerous tumour. Polypi appear to be a common predisposing cause of cancer. The history in vaany cases clearly shows their presence for a considerable time before the cancer started. These cases are dealt with in full in considering the subject of multiple polypi. Morbid Anatomy. — Cancer of the colon always originates in the glands of Lieberkiihn, and is of the so-called columnar-celled variety, or aden-ocarcinoma. No other type of carcinoma occurs in the colon, though there may be considerable variations due to secondary or degenerative changes. Colloid degeneration is not uncommon, and in rapidh^ growing tumours the so-called encephaloid type of degeneration is seen. Occasionally there is a tendency for the fibrous-tissue elements to preponderate, and this results in the scirrhous type of growth. Scirrhous carcinoma is most common in growths of the sigmoid ; but it is always a rare form of cancer of the colon. The scirrhous growths do not project into the bowel, but cause a tight stricture of the lumen due to the growth spreading circularly in the submucous layer. The appearance of such tumours is often that of a tight ring-like stricture, the outside of the bowel being grooved as if a string had been tied round it. These scirrhous growths may cause considerable stricture without any ulceration of the mucosa. The common adeno-carcinoma is a more or less nodular or cauhflower-like outgrowth of the mucosa projecting into the PLATE V Cancer of the Pelvic Colon as seen through the sigmoidoscope. OF THE COLON 251 bowel lumen. The surface may or mav not be ulcerated, depend- ing upon the time it has existed and the amount of traumatism to which it has been subjected. On the outside of the bowel, over the base of such a tumour, there is generally a scar-like depression or hollow, and in addition to the narrowing of the lumen caused bv the tumour, there is almost invariably a certain amount of contraction. Rarely, the tumour exists as a polypus hanging loose in the bowel lumen, and in one of my cases there were several such polvpi showing malignant changes. (See Fig. 64.) y-'/V 59. — An early carcinomatous ulcer of tlie sigmoid flexure. Resecced by the author from a man, age 46. All cancers found in the colon are, however, essentially the same, namely, adeno-carcinomata, and the various different tvpes often described are merelv due to degenerative or other changes. Cancer of the colon is almost invariablv a primary lesion ; but there are a few rare and interesting cases where the growth appears to be secondary to another, higher up in the alimen- tary canal. In these rare instances of secondarv carcinoma the infection appears to have been direct. That- is, the cancer cells from one growth have apparently passed down the bowel and become implanted in the mucous membrane of the colon, pre- sumably through an abrasion or some breach of surface. It is, of course, possible that the two growths have arisen separateh', and have no connection with each other ; but in at least one of the cases the appearances suggested that the lower growth was secondary to the upper one. 252 MALIGNANT DISEASE In a case recorded by Mr. C. ]\Iorton,* the cscum was excised for cancer, and the ileum anastomosed to the ascending colon. The patient recovered ; but five years later there was a cancer in the transverse colon, and the patient died after an operation for its removal. I have found several instances of more than one growth in the same colon in different parts. Mr. Littlewood recently reported two such cases, j In one, the patient, a woman aged 52, had a cancer in the splenic flexure of the colon, and another in the rectum. In the other case, a man aged 69 had a cancer in the ascending colon and another similar growth in the rectum. A case of particular interest is recorded by Mr. G. Simpson, + in which there were two primary growths in the colon. One was in the caecum ; and on microscopical examination was found to be a columnar-celled growth undergoing colloid degeneration ; and the other was in the hepatic flexure, and was a t\'pical scirrhous cancer with numbers of irregular cells arranged in lines. Metastatic growths of the colon secondary to cancer in parts of the bod\' other than the alimentary tract are very uncommon. Such a case is, however, recorded by Mr. Arbuthnot Lane. The patient was a woman, who many years previoush' had had her breast removed for cancer. There were no signs of recurrence in the scar or glands, but a growth in the sigmoid was detected. At the operation a cancerous growth was found extending from the mesentery into the sigmoid and stricturing it. Other growths were found of a similar nature in the rectum and in the ascending colon. There was also growth in the liver. The whole colon was removed and the ileum stitched into the anus. The patient died three weeks later. It was found that the growths were secondary carcinoma, and involved in a varying degree almost the whole colon. The following remarkable case of several separate malignant growths in the colon was under m}- care at St. Mark's Hospital : Case. — The patient, a man aged 46, had a small adeno-carcinoma in the centre of his sigmoid flexure. This was successfully resected, and he remained apparently well for nine months, when he was examined * Brit. Med. Jour., Oct. 29, 1904. f Lancet, Jan. 11, 1907. t Brit. Med. Jour. Dec. 7, 1907. OF THE COLON 253 with the sigmoidoscope because he was again passing blood. It was then seen that he had several large polypi, some six inches or more above the line of the previous resection, the intervening mucous membrane being normal. One of these polypi was removed, and on examination was found to be a typical carcinoma. A second operation was performed, but the patient died from peritonitis. Post mortem, six of these polypi with long slender stalks were discovered, the highest of which was nine inches above the growth originally removed. Two of these were examined, and one showed typical cancer formation. There were no signs of secondarv deposits anywhere. The only reasonable explanation of this curious case seems to be that the original growth resulted from a simple polypus which had become malignant, and that, later, the remaining polypi also took on malignant change. The Lines of Extension of the Growth. — The study of the directions and ways in which cancer of the colon extends is of the utmost importance, for unless these are known it is not possible to so plan an operation as to be reasonably certain of removing the entire growth. And it is only when operations for cancer are planned according to the known methods of extension of the growth that really successful results can be obtained. As already stated, cancer when it affects the colon tends for a long time to remain localized to the bowel-wall, and it is excep- tional to find the glands in the mesocolon, and especially the retro-peritoneal glands, involved, except in very late cases. Out of thirty cases in which glands were specially looked for, enlarged glands were present in the mesocolon in only five, and retro- peritoneal glands in only three cases. In only two cases was there a secondary deposit in the liver. The thirty were ail cases in which an operation had been performed, and not those reaching the post-mortem table after dying from cancer. Of course, a much higher proportion of secondary deposits would be found if cases of advanced and inoperable disease were taken. At the stage when cancer of the colon is usually detected, enlargement of the glands in the root of the mesocolon and behind the posterior peritoneum is exceptional, the growth tending rather to spread in the bowel-wall, and to involve onh' those glands in immediate contact with it. We are too apt to assume, because enlarged glands are found in the neighbourhood of a mahgnant growth, that they are therefore the seat of cancer cells. Frequenth', however, this is not the case. 254 MALIGNANT DISEASE Mr. Clogg, in a similar investigation, found that in only two- thirds of the cases in which there were enlarged glands could cancer cells be found. While enlarged glands are not uncommonly present in immediate proximity to the growth, and in the fat around the bowel, they are not very common at the root of the mesocolon Fig. 60. — Cancer of the sigmoid flexure. A transverse microscopical section of the colon through the centre of the growth. The gland in the lower edge does not shoW any cancer cells. 'J'he growth is spreading in the submucous layer. Photograph from a specimen prepared by Mr. i.enthal Cheatle. or in the retro-peritoneal tissue ; and in many cases the glands that are enlarged are not cancerous. While there are certainly exceptions, as a rule cancer of the colon grows very slowly, and seldom gives rise to secondary deposits in glands or other viscera. I have seen a patient who six years previously had colotomy performed for cancer at the recto-sigmoidal junction (a piece OF THE COLON 255 of the growth was at that time removed and examined microscopically) . and who was still in good health and free from an\- signs of secondary deposits. Mr. Swinford Edwards had a similar case, in which the patient lived for over five years without secondary deposits forming. \\'hen secondary deposits do occur, thev are invariably found in the liver, and practically never elsewhere unless thev are also present in the liver. Invasion of other organs, such as the stomach, bladder, and small intestine, are not uncommon, but these do not come under the head of secondary deposits. Though cancer of the colon does not, as a rule, spread rapidly, and but seldom 'causes secondar\- deposits, its victims do not often Hve long, as it soon produces obstruction, and, if un- operated upon, a quite small and localized growth will bring about a fatal result in a very few months.. Cancer of ths IleoccBcal Angle. — This is, next to the sigmoid flexure, the commonest situation for cancer of the colon. The commonest situation for the growth to start is at the ileo- caecal valve ; other situations being on the posterior csecal wall, at the junction of the caecum and ascending colon, and in the appendix. Cancer of the Transverse Colon. — Growths in this situation tend very soon to involve the stomach. Out of eight cases of cancer of the transverse colon of which I have notes, four had spread to the stomach, and in two a fistula communicated between the colon and stomach. Cancer of the Sigmoid Flexure. — This may occur in any part of the sigmoid flexure ; but the commonest situations are at about its centre, — that is to say, at the apex of the loop and at the recto-sigmoidal junction. Symptoms. These are most variable, and depend upon a number of factors, such as the type and stage of the disease, the situation, and the condition of the patient. So greatly do the symptoms var\- in different cases, that we might almost say that any s\'mptom referable to the colon may be produced b\- cancer. None, unfortunately, are characteristic. As a rule, they are at first those of an irritative lesion in the colon, and later of a stenosis. A growth may exist in the colon for long periods without producing any symptoms of importance, 2=^6 MALIGNANT DISEASE or causing the patient any serious inconvenience. Often the earliest sign is some irregularity in the action of the bowels. There mav be shght attacks of diarrhoea, occurring fairly fre- quently and without any apparent cause ; or, on the other hand, Fig. 6i. — Tumour high up in the sigmoid flexure (sigmoidoscopic). the bowels, which had previously been regular, have a tendency to become constipated, and occasional aperients are required. Sometimes again, the first sjTnptom is the presence of mucus m the stools, either as slime or casts, and accompanied b}- slight Fig. 62. — Malignant growth at the lower end of the sigmoid flexure growing from the anterior bowel-wall (sigmoidoscopic). diarrhoea. Such cases are usually first diagnosed as chronic colitis ; and I have seen seven such cases which proved on examination to be cancer of the pelvic colon. Pain or discomfort in the abdomen is often an early svmptom. The pain may OF THE COLON 257 either take the form of occasional attacks of colic, or of a more or less constant sense of abdominal discomfort, often described as a dull, dragging pain. Flatulence, requiring the constant passage o f wind, is another early symptom in some cases. I recently saw a patient who complained of slight colicky pain coming on in the afternoon after he had been standing for some time, and the presence of mucus in the stools. These symptoms had begun about nine months previously as the result of an attack of indigestion. There were no other symptoms, and the patient looked in excellent health ; but a sigmoidoscopic examin- ation revealed a cancerous ulcer in the sigmoid flexure. I once saw a case in which the first symptom of a growth in the sigmoid flexure was a sudden and severe haemorrhage from the rectum ; but this is unusual. As a rule, bleeding is conspicuous by its absence in the early stages of cancer of the colon. The onset of symptoms is often quite abrupt, and may be attributed by the patient to some dietary indiscretion. It is obvious that the symptoms just detailed are so compara- tively insignificant, and so common as the result of other and less important conditions, that it is improbable they should give rise to any suspicion of cancer of the colon. Certainly no one would venture to make a diagnosis of growth upon such evidence. Nevertheless, they are of the utmost importance, for if we are to treat cancer of the colon successfully, we must be able to diagnose the condition while the growth is in its earliest stage. When such symptoms are complained of, the patient should be carefully examined, if possible with the sigmoidoscope, as by this means the growth can often be detected at quite an early stage, when removal will be successful. In the later stages the symptoms are more definite. Pain is more or less constant. It may take the form of occasional sharp attacks of colic, or be of a dull, constant character. When the growth is in the caecal region, the time at which the pain comes on sometimes bears a relationship to meals, being worse some three or four hours after food. When in the pelvic colon it may have a relationship to defaecation. The pain is as a rule not well localized, but occasionally may be. Sometimes the patient is conscious of an obstruction at some part of the colon, and will state that he feels there is difficulty in the passage of the bowel contents past a certain point. 17 25^ MALIGNANT DISEASE Constipation occurs almost always, sooner or later. At first this is easil\- relieved b\- aperients ; but later, aperients bring on pain, or cause diarrhoea. As a rule, irregularity of the bowels is the condition which first occurs, and later obstruction. Some- times complete obstruction is the first s\Tnptom noticed. In some others it is an attack of partial obstruction due to faecal impaction. This is relieved satisfactorily by aperients or enemata, and often the true cause of the condition is missed. All cases of faecal impaction should be carefull}'- examined, as the condition usually results from slight stricturing of the bowel. As already mentioned, diarrhoea is often an earl\- sjmiptom, and may also occur in the later stages. It is, however, spurious, and careful enquiry wiU ehcit the fact that but httle is passed. Fi^. 63. — Sudden narrowing of the bowel just below a growth in the sigmoid fle.xure. (The growth was adherent in the left iliac fossa.) (Sigmoidoscopic. ) It is due to the irritation set up by the growth and by the faeces retained above it. Occasionally diarrhoea is a very marked feature of the condition. Blood in the stools is seldom present in the earh* stages, and in many cases is absent throughout. Although it is the exception to see blood in the stools, a careful microscopical examination wiU usuaUv reveal the presence of a few blood corpuscles. There are two s\-mptoms which are often mentioned as of importance, namety, loss of weight or cachexia, and ribbon or pipe-stem faeces. Neither of these is, however, of any im- portance or diagnostic value. Loss of weight only occurs in the late stages when there is a large growth, or when diarrhoea is a prominent symptom ; and it is commoner in other conditions OF THE COLON 259 than in cancer. Pipe-stem faeces can only occur in rectal cancer when the growth involves the anus, as it is obvious that the fasces will take their shape from the last orifice through which they pass, and that even if the faeces became narrowed in passing a stricture in the colon, they would be re-moulded in the rectum. In a few instances the first thing to draw attention to the growth is the presence of a tumour in the abdomen. This is more often the case when the growth is in the caecal region, as here Fig. 64.— An adeno-carcinomatous polypus of the pelvic colon. From a specimen of the author's. The polypus was detected by the sigmoidoscope, and later resected, together with two inches of the^colon ; the ends being anastomosed. {Natural size.) a growth may reach a considerable size before any symptoms sufficient to draw the patient's attention to his condition have arisen. Although it is fairly easy to make a diagnosis of cancer of the colon when a palpable tumour is present, it is of the utmost importance that the diagnosis should, if possible, be made before this, as by the time a tumour has reached a sufficient size to be palpable the best time for its removal has probably passed. It cannot be too strongly emphasized that if cancer of the 26o MALIGNANT DISEASE colon is to be successfully treated, it is necessary that patients should be carefully examined directly there are any symptoms the least suspicious of that condition. Secondary Results of Cancer of the Colon. — Intestinal obstruction is by far the commonest of these, and may be said to occur in almost all cases. It is often the symptoms of obstruc- tion which first call attention to the disease. The obstruction is never complete, and there is always a slight lumen which will allow fluid contents to pass. In many cases it remains partial for a long period, giving rise to the typical symptoms of chronic obstruction, and resulting in hypertrophy and dilatation of the bowel above the stricture. Sooner or later, however, the narrow opening becomes blocked, either from a hard mass of faeces or a foreign body becoming impacted in it, and acute obstruction then sets in. This may also result from a kink occurring as the result of the growth having become adherent to some other organ or structure, or owing to the mesentery becoming shortened from contraction of the fibrous tissue about the growth. Acute obstruction may also occur from intussusception started by a growth in the colon. The late Mr. Barnard found five cases of this condition in the records of the London Hospital. Ulceration of the growth does not occur at so early a stage of the disease as in the case of rectal cancer, probably owing to the fact that the colon is not so subjected to injury from the passage of hard faecal masses. Spontaneous anastomosis occurred in three of the cases in my series. In two, the transverse colon communicated with the stomach, and in the other with the ileum. Tuttle operated upon two cases, in one of which the sigmoid communicated with the ileum near its termination ; and in the other the two extremities of the sigmoid flexure communicated with each other and short- circuited the central portion. As a rule the anastomosis is only a small opening, but some- times it is large enough to allow most of the intestinal contents to be short-circuited. The two parts of bowel first become adherent at the base of the growth ; and then the growth extends into the walls of the adherent viscus. Later, ulceration occurs, and the blood- supply being poorest in the central portion a communication is established between the two. In a few cases, however, the OF THE COLON 261 communication occurs differently. The growth in the colon becomes ulcerated, the ulcer perforates the bowel-wall, and a pericolic abscess forms, communicating by the ulcer with the colon. This abscess then becomes adherent to some other viscus, such as the stomach or ileum, and eventual^ bursts into it and establishes a communication between it and the colon bv wa\- of the abscess. -—^—.^-42^ Fig. 65. — Diagrams illustrating different ways in which spontaneous anastomosis may result from a malignant growth in the colon. I. — Anastomosis between stomach and transverse colon. II. — Anastomosis between ileum and sigmoid flexure. III. — Anastomosis between ileum and transverse colon. IV. — Anastomosis between two loops of sigmoid fle.xure. V. — Anastomosis by abscess formation between stomach and transverse colon. Malignant peritonitis is very rare as a complication of cancer of the colon. Acute dilatation of the colon may occur above a malignant stricture. The dilatation may involve the colon immediately above the stricture, or may affect the caecum only. Thus, the stricture may be in the sigmoid flexure, and the colon between this and the caecum may be almost normal, and yet extreme dilatation of the caecum may be found. This is generally a terminal and fatal compHcation. 262 MALIGNANT DISEASE Fatal Termination in Cancer of the Colon. — Cancer of the colon seldom kills directh-^, or even so directly as cancer of most other organs. The fatal termination may occur from one of several secondary consequences. It may be from acute intestinal obstruction ; from a toxaemia due to the absorption of poisons in the foul bowel contents retained above the stricture ; from acute peritonitis consequent upon a perforating ulcer in the dilated bowel above the growth ; or from extensive suppuration due to perforation of the growth or of an ulcer in the bowel above it. Sarcoma of the Colon. — This is a ver}^ rare form of disease of the colon, and I have onty been able to find seven cases of the condition. As one would expect, the patients are j^ounger as a rule than is the case with cancer. le ages in these seven cases were as follows : — I. Male, age 17 5. Male, age 8 2. Female ,, 50 6. Female ,, not stated 3. Male ,, 12 7- >' .. 5 4. Female ,, 21 In all these seven cases the growth was in the csecal region. It is generally a fusiform-celled sarcoma, but in one case it was myxo-sarcoma, and in one a fibro-sarcoma. Sarcoma differs markedly from cancer in appearance, as it looks as if it had invaded the bowel-w^all from outside. The mucous mem- brane is at first intact, and is stretched over the tumour. It originates in the interstitial tissues of the bowel-wall, and tends to spread along the submucous and subperitoneal laj'ers, both circularly and longtitudinally. In cut sections these two layers are seen to be greatl}^ thickened and to consist entirely of sarcomatous tissue. The growth does not affect the mucous membrane earty, and it does not tend to ulcerate into the bowel lumen. There was no ulceration in an 3^ of these seven cases. In some, the growth seems to spread along the bowel, forming a tubular stricture, and forms outgrowths or tumours under the peritoneum ; while in others it tends rather to spread into the bowel and form a large tumour filling up the lumen. The growth may apparenth;^ start in the subperitoneal layer, and in one patient almost the whole growth was outside the muscular coat. It appears to originate in the neighbourhood of the ileocaecal valve, but there is nothing to show exactly OF THE COLON 263 where it started. Marked ascites due to involvement of the peritoneum was present in one of the cases. Treatment of Cancer of the Colon. Cancer of the colon can be very successfully treated by opera- tion, and excellent results can be obtained as regards both the subsequent comfort of the patient and freedom from future recurrence of the tumour. As has already been pointed out, growths of the colon tend to remain locahzed to the bowel-wall for a long time, and do not readily give rise to secondary gland-involvement in the root of the mesentery or posterior peritoneal chain of glands. They grow slowly, and but seldom, and only in their later stages, give rise to metastatic deposits in other parts of the body. They do not readily become adherent to important organs, though an exception to this statement must be made in the case of growths of the transverse colon, which frequently involve the stomach. Large portions of the colon can be removed without causing the patient any serious subsequent inconvenience, or preventing him from enjoying life. The operation for excision of a cancer of the colon does not as a rule present any very serious difficulties, and there are many different methods of dealing with the bowel, after the growth has been excised, which can be adopted according to the exi- gencies of the case. The most important factor, as in cancer anywhere else in the body, is early diagnosis. Our methods of diagnosing cancer of the bowel have much improved in recent years, and it is now the exception for a growth to reach a large size before it is recognized. Perhaps fortunately, cancer of the colon draws attention to itself at an early stage by producing obstruction. In many cases cancer is first detected at an operation under- taken for the relief of obstruction. It will therefore be necessary to consider first the methods of deahng with cases of obstruction of the colon due to cancer, and then to consider the treatment of the growth itself. The actual details of the different operations are considered separately, and I shall deal here only with the indications for operation and the choice of methods. The Treatment of Obstruction due to Cancer of the Colon. — Most cases of cancer of the large bowel present them- selves to the surgeon with symptoms of obstruction either acute 264 MALIGNANT DISEASE or chronic. When there is acute obstruction, the obvious indica- tions are to relieve the obstruction, which immediately threatens a fatal issue, rather than to excise the growth, which may be dealt with afterwards, and at any rate can only be directly fatal at some later date. The surgeon should not be tempted into doing a complete operation, which, though it may be ideal in theory, is in practice too often attended by fatal consequences. Patients with acute obstruction of the colon are generally in a profound toxemic condition owing to the accumulation of poisonous substances in the large bowel, and are not in a state to stand any but the simplest and briefest of operations. More- over, to excise the growth and anastomose the ends in a patient with acute obstruction, is to leave the patient with a newly- formed joint in the bowel which will certainly be subjected almost immediately to the pressure of the accumulated contents of the bowel above the previous stricture, and this is putting more strain upon the surgeon's handiwork than is at all justifi- able. When there is chronic obstruction, but the symptoms are not acute, the choice of method must depend upon whether it is possible entirely to empty the bowel above the stricture. If it is possible by means of aperients to satisfactorily empty the bowel, and the surgeon is certain that there is no accumulation of faecal material above the growth, then resection of the growth and immediate end-to-end or lateral anastomosis of the bowel would seem justifiable. But if the bowel cannot be so emptied, the case should be treated in the same way as if acute obstruction existed. This, though it entails the patient undergoing at least two operations, is infinitely safer than performing an anastomosis with accumu- lated faeces above the line of suture. I have collected a large number of cases with the view of ascertaining the safest methods of deahng with cases of cancer of the colon, and for this purpose have taken only those in which the growth has been removed either at the first or at some subse- quent operation, and have divided these into groups according to the method adopted in each case. Cases of Immediate Excision of the Growth, with Anastomosis of THE Bowel, either end-to-end or laterally, by Suture. ^ n • J r> J Percentage Cases. Dud. Recovered. Mortality. 86 32 54 37 Six cases recovered with a faecal fistula. OF THE COLON 265 Cases of Immediate Excision with Anastomosis by Mlrphy's Button. Cases. Died. Recovered. ^i[^^. 18 7 II 38 Immediate Excision of the Growth, the Ends of the Bowel being brought out of the Abdomen and an Artificial Anus estab- lished. Followed later by end-to-end Anastomosis or Destruction of the Spur (Paul's Method). Cases. Died. Recovered. ^S 23 4 19 17 Cases in which an Artificial Anus was made and Excision of the Growth performed later. Cases. Died. Recovered. ^f"'1"/^ Mortality. 505 nil. Mo3Tiihan's figures in his book on operations on the abdomen give similar results ; they are : — Immediate excision and anastomosis — 3 cases with i death. Paul's operation — 12 cases with i death. Colotomy followed by excision — 17 cases with 3 deaths. The above figures show that, while excision with immediate anastomosis is the most popular method, it is attended with by far the highest mortality. The figures indicate that colotomy followed by excision is safer than excision and bringing the ends out ; but several of the cases in m\^ tables were not done by Paul's operation with glass tubes. It seems probable, therefore, that both methods are about equalh" satisfactory as regards a low mortality. Immediate excision and anastomosis is attended by more than double the mortality of the operations in which an artificial anus is established ; and in spite of its obvious advantages it should certainly not be performed except where the bowel can be completely emptied. The fact that a faecal fistula occurred in several of the cases that did recover, shows that the hne of suture did not hold, and that the patient had run a very serious risk of losing his Hfe. Paul's operation, in which the growth is excised at the first operation, and the two ends of the bowel are brought out and glass tubes tied into them to form an artificial anus, has the obvious advantage over colotomy followed by excision, that the 266 MALIGNANT DISEASE growth is removed at the earhest possible time. It does not, however, save the patient from a subsequent operation, as a secondar}^ operation to close the artificial anus will almost cer- tainh^ be necessary. In the case of colotomy followed by excision of the growth, three operations may be necessary, the third being done to close the artificial anus after the growth has been excised and the continuity of the bowel restored. The third operation may be avoided b}- closing the artificial anus at the second operation ; this, however, considerabh^ increases the risk of the second operation. One objection to Paul's method is, that if the growth is to be excised properly, together with its l^rmphatic area, the operation will in many cases take some time to perform. This sometimes renders it unsuitable where acute obstruction exists at the time. Also, it is, of course, only possible where, after excision of the growth, the two ends of the bowel can easily be brought up to the surface. An operation for cancer of the colon should aim at excising. not onlv the growth, but also the whole of the lymphatic area in the mesentery, and, if possible, the chain of glands in the root of the mesenterj;' and along the vessels passing to the affected portion of bowel. This is not a very difficult matter in most parts of the colon, but it often necessitates the sacrifice of a considerable length of gut in order to make certain that the blood-supply to that left behind is good. A large wedge-shaped piece of mesocolon should be removed, and the peritoneum at the back of the abdomen stripped up sufficiently to allow the fat and glands to be cleared out. As I have already shown in discussing the pathology, growths of the colon spread round the bowel-wall and up and down in the submucous layers, and cancer cells frequently appear in this layer at some little distance from the apparent edge of the growth. Operations, therefore, in which the growth is excised but the bowel is not resected, or in which the bowel is cut close to the growth, are more than likely to fail in eradicating the disease. The entire circumference of the bowel should always be removed, and the gut be divided at least an inch, and if possible more, from the extreme hmits of the growth both above and below. Another plan for deaUng with growths in the colon must be mentioned, namely by immediate short-circuit of the growth by lateral anastomosis, foUoM^ed later by excision and closure of the OF THE COLON 267 ends. This method is certainly inferior to those previously men- tioned. Indications for Removing the Growth. — It is too often supposed that because, on opening the abdomen, the growth is found to be large or to be accompanied by a number of enlarged glands, it is therefore useless to remove it. In discussing the pathology it was pointed out that cancer of the colon tends to remain localized for long periods, and that the enlarged glands are frequently not cancerous ; they do not, therefore, necessarily mean that the tumour has passed beyond the stage of successful removal, or that if the glands cannot all be removed, rapid recurrence will necessarily foUow. Even adhesions are often not cancerous, and if the tumour can be removed and the con- tinuity of the bowel ultimately restored without very serious risk, the operation should most certainly be proceeded with. There are several instances in which there were enlarged glands in the mesocolon at the time of operation, and yet the patient did not develop any signs of recurrence of the growth. Mr. Charters Symonds records a case in which enlarged glands were left in the mesocolon, but the patient remained free from recurrence ten years later. Paul records two cases. One, in which glands as large as filberts were present in the root of the mesentery, was well and free from recurrence five years after excision of the growth. In the other case there were also many enlarged glands, but the patient was free from recurrence two-and-a-half years after the operation. Adhesions of the growth to other viscera should also not necessarily be considered as contraindicating excision, unless the adhesions are to some part which cannot be removed. If they are to the stomach, a portion of the latter viscus can be excised with the tumour. I know two cases in which this was successfully done. Similarly, if the ileum is involved, a portion of it can be resected. In the case of adhesions to the abdominal wall, there is no great difficulty in removing the affected portion, providing it is not too extensive. Excision of Growths in the Ccscal Region.— -These lend them- selves readily to extensive resection, as the entire csecal angle of the colon can be freed and removed together with the growth. Any attempts to resect portions of the caecum will probably end in failure, both as regards removal of the disease, 268 MALIGNANT DISEASE and also satisfactory restoration of the parts. The peritoneum attaching the caecum and ascending colon to the posterior abdominal wall should be divided on each side, and the entire caecal angle stripped up, together with the growth and tissues in the iliac fossa. Next, the vessels should be defined, care being taken to avoid the duodenum, ureter, and spermatic vessels. Those vessels that will require ligature are the ileocolic and caecal arteries. If there are any glands along the line of the right ileocolic artery, it may be further necessary to ligature the right colic artery which lies close to it, in order to make certain of clearing them away. The entire caecal angle and tumour can now be easily brought out of the wound. Clamps are next applied to the ileum and colon, and the tumour and caecum are cut away. If it has been necessary to ligature the right colic artery, the greater part of the ascending colon must also be removed, as its blood-supply has been damaged. The next step is to deal with the bowel ends. It is most impor- tant to see that there is a good blood-supply to the stump of bowel left after division. If this is not satisfactory, more bowel should be resected until an efficient blood-supply is obtained. The choice of a method must, of course, depend very largely upon the circumstances of the case. It will not always be possible to bring the stump of the ascending colon sufficiently out of the wound to establish an artificial anus by Paul's method. If, however, it is possible to bring up the stump, then a large glass Paul's tube should be tied into it, and a similar tube into the stump of the ileum. These two portions of bowel should then be stitched together over an area of about two inches, to facilitate the use of an enterotome afterwards. Should it be decided to anastomose the bowel at once, there are two methods available. The stump of the ascending colon can be closed up, and the ileum implanted into its side or into the transverse colon ; or, the stumps may be joined end-to-end by suture, after their respective openings have been made to correspond in size by any of the recognized methods. There is still another method, namely, to close both ends and do a lateral anastomosis, but this has nothing to recommend it, and several disadvantages. Undoubtedly the best procedure is to close the end of the colon and implant the end of the ileum into it. If much of the ascend- ing colon has been removed it will be necessary to implant the OF THE COLON 269 ileum into the transverse colon. Closure of the colon, and lateral implantation of the ileum into it, can be very rapidly done, and makes an excellent joint. Charters Symonds in his Lett- somian Lectures in 1908, advocated using a Murphy's button reinforced with Lembert sutures to make the anastomosis. Stitching", however, is as quick, and certainly a preferable method. End-to-end anastomosis is more difficult, only applicable in some cases, and much more hable to failure, while it does not seem to have any advantages over lateral implantation. Owing to the fluid nature of the contents of the ileum, imme- diate anastomosis is much safer, even when obstruction is present, in cases of caecal cancer than in cancer of the descending or pelvic colon. In my collected cases there were sixty-five cases of excision of the csecum for cancer, with nineteen deaths from the operation. Cancer of the Hepatic Flexure. — Excision of growths of the hepatic flexure is not often possible, because, there being as a rule no mesentery, the growth early becomes adherent posteri- orly. In my series there is only one instance of successful resection of a growth of the hepatic flexure, and in this case there was rapid recurrence. Cancer of the Transverse Colon. — Excision of growths in this situation is not especially difficult, as this portion of the colon can be drawn out of the abdominal cavity. In my series there are five cases of excision of a growth in the transverse colon. In one, an artificial anus was first established above the growth, and, later on, the growth was excised and the bowel joined by sutures ; the patient recovered. In one case Paul's method was adopted ; and in the three others the growth was excised, and the colon joined end-to-end by sutures at once. In two of the cases the stomach was involved in the growth, and an ellip- tical portion of this viscus was excised, together with the growth. Four recovered. The case that died was one in which immediate end-to-end anastomosis was performed. In another of the cases of immediate end-to-end union, a faecal fistula formed after the operation. Cancer of the Splenic Flexure — There are two cases in which excision was performed. In one the bowel was anastomosed end-to-end by suture ; the patient died. In the other the transverse colon was united to the sigmoid flexure; this patient recovered, but a feecal fistula formed. 270 MALIGNANT DISEASE Cancer of the Sigmoid Flexure — In by far the majority of cases of cancer of the colon the growth is in the sigmoid flexure. With the exception of those at the extreme lower end, these growths may be readily excised, owing to the mobility of this part of the colon. The sigmoid flexure is, however, not so suitable for end-to-end anastomosis after excision as the caecal angle, owing to the fact that the faecal contents are more solid, and the suture line will be subjected to a greater strain after operation. Paul's operation is undoubtedly the safest method of dealing with growths in this situation. The mortality from it in growths of the sigmoid is very low indeed. Paul himself has performed it a great many times, with only one or two deaths. M. J. Boselius states that out of twenty-eight cases operated upon by this method in the Breslau Hospital there were only four deaths ; whereas formerly, when end-to-end union was performed, the mortality was fifty per cent. Hochenegg had only one death in fourteen cases. In my series there are five resections of the sigmoid for cancer with immediate end-to-end anastomosis ; of these, four died from the operation. Eight were treated by Paul's method, or by the establishment of an artificial anus previous to excision, and of these none died. There can be no doubt, therefore, that in spite of the obvious disadvantages of a temporary artificial anus and of a double operation, the best method of dealing with the bowel after excision of a growth in the sigmoid is to bring the ends out and establish an artificial anus, this being subse- quently closed by a second operation. This operation does not incur much more danger than a simple colotomy. Colotomy above the growth, followed by excision, has the serious disadvan- tage that there is considerable danger of not getting the surface of the abdomen clean enough for the second operation, and a risk of soiling the peritoneum during its performance. In excising a growth of the sigmoid flexure care should be taken to go well wide of the growth (at least an inch on each side of it, and preferably more), and to make a clean sweep of the mesocolon containing the lymphatics, and the portion of bowel in which the tumour is situated. The peritoneum can be stripped up over the iliac vessels if necessary, and any glands in this situation removed. The glands, if present, will probably be found lying close to the sigmoid and inferior mesenteric arteries. Mr. Moynihan states that there is always a gland situated on the OF THE COLON 271 inferior mesenteric artery, and that the greater part of the sigmoid loop, the mesocolon, and the inferior mesenteric artery must be removed entirely. This makes the operation a very extensive one, and, although it has been shown that after ligature of the inferior mesenteric artery there is still an adequate blood- supply to the parts that remain, such an extensive operation seems hardly necessary in all cases in view of the fact that other observers have not found this enlarged gland on the vessel to be by any means invariably present. The presence of glands along the inferior mesenteric artery should be looked for, and such Fig. 66. — A, Inferior mesenteric artery ; B, ligature without destroying anastomosis ; C, ligatures breaking the anastomosis. [Jamieson and Dobson, Proc. Ro^/. Soc. Med., Vol. 2, 1909.] extensive removal only carried out if they are discovered, though, even when enlarged, it does not necessarily follow that the gland is carcinomatous. Considerable difficulty exists when the growth, as is not infre- quently the case, is situated just above the recto-sigmoidal junction. When the growth is here it will be so deeply situated in the pelvis that considerable difficulty may be experienced in removing it ; but by using the Trendelenburg position, and freely incising the peritoneum at the front and sides of the growth, it can always be removed. The chief trouble is expe- rienced in deahng with the bowel afterwards. There are three alternatives : — 272 MALIGNANT DISEASE 1. To close or pack off the upper end of the rectum, and to bring the stump of the sigmoid out of the abdomen and form an artiiicial anus. 2. To remove the entire rectum and bring the stump of the sigmoid down to the anus. 3. To anastomose the ends b}/ means of a tube tied into the sigmoid and passed down through the rectum and out of the anus. The first method has the objection that it leaves the patient with a permanent artiiicial anus ; while the second involves a most formidable operation and sacrifices a normal rectum. The third method gives quite satisfactory results, and enables the continuity of the bowel to be restored in cases where end-to- end anastomosis is impossible. It will be described in detail later. Summary. 1. In cases where acute obstruction is present at the time of operation, a temporary artificial anus should always be made, and excision of the growth postponed till a later time ; or the growth should be excised and the ends of the bowel brought out. 2. Unless the bowel above the growth can be entirely emptied before operation, an artificial anus should be established before proceeding to excise the growth ; or Paul's operation be done. 3. In excising the growth, the bowel should always be resected, and at least an inch of normal bowel removed on each side of the growth. 4. Whenever possible the lymphatic area should be cleared with the growth ; but inability to do this is not necessarily a bar to successful removal. 5. Immediate end-to-end anastomosis after excision may be performed in dealing with the right half of the colon, but is dangerous on the left side. 6. Paul's operation, or colotomy followed by excision, is by far the safest operation when excising growths of the sigmoid. 7. The presence of enlarged glands, or adhesions to other structures, should not necessarily be taken as contra-indicating resection, providing removal is possible. Recurrence of the Growth after Excision. — Owing to the fact that cancer of the colon tends to remain localized for OF THE COLON 273 long periods, and but seldom gives rise to metastatic deposits, recurrence after operation is not very common. I have not collected a series of statistics to show the frequency of recurrence, because owing to the wideh- different operations performed by surgeons, and in different cases, any such statistics would be valueless. Until a more or less uniform operation becomes recognized in excising growths of the colon, such statistics can hardly be of much value. I have, however, been able to find many records of cases in which the patient, after resection of a growth from the colon, has remained free from recurrence for long periods. Mr. S}Tnonds has recorded a case in w^hich the patient, after a growth in the ileocaecal angle had been resected, remained free from recurrence ten years later. Mr. Paul records two cases free from recurrence six and five years respectively after excision. Mr. Clogg records two cases six and four years after operation and free from recurrence. Mr. Movnihan records two cases remaining well seven years after operation ; and nine cases well three years after. Boselius records four cases free from recur- rence five years after operation. These are sufficient to show that very long periods of freedom from recurrence may be obtained after resection of the colon for cancer. Palliative Operations. — Even when the growth cannot be removed, much may be done by the performance of a suitable operation to render the patient more comfortable and prolong his life. The operations that ma^^ be performed for this purpose are : — 1. Excision of as much of the growth as can be got away. 2. Short-circuiting the growth. 3. Making an artificial anus above the growth. Some surgeons have advised that, even when it is found at the operation that there are glands which cannot be removed, or metastatic deposits in the liver, the best plan is still to excise the primary growth, and that this will give the patient a longer lease of life than short-circuiting. There is a good deal to be said for this view, and always the possibility that the glands which are not removed are not cancerous. If the primary growth can be easilv removed without much danger to the patient, this is probably the best treatment ; but it does not seem right to subject the patient to a dangerous and prolonged operation if there are secondary deposits already present which lo 274 MALIGNANT DISEASE cannot be removed. Short-circuiting the growth is undoubtedly the best method when it is found that excision is impossible. It does away with the danger of obstruction, and does not leave the patient with the discomforts of a colotomy. If the growth is in the caecum, the ileum should be divided, the caecal end closed, and the proximal end implanted into the ascending or transverse colon. This gives a better result, and is just as easily performed as lateral anastomosis in this Fig. 67.- — Diagram showing dififerent methods of short-circuiting a tumour of the colon. I. — Ileum implanted after division into ascending colon. II. — Ditto, but caecum excluded and opening by fistula on skin surface. III. — Ileo-sigmoidostomy after dividing ileum. IV.— Ditto, and exclusion of colon with fistula to skin. V. — Transverfe colon anastomosed to sigmoid. VI. — Ileo-sigmoidostomy for growth in colon. situation. Ileo-colostomy by lateral implantation seems to be the best operation for growths in the right half of the colon, and in the transverse colon. An even better operation, probably, is to divide the colon above the anastomosis and bring the excluded portion to the skin, as this does away with the possibility of feces accumulating in the excluded portion of the colon ; it has, however, the disadvantage of leaving the patient with a fistulous OF THE COLON 275 opening. When the growth is in the left side of the colon, the choice lies between lateral anastomosis between the transverse colon and sigmoid and ileo-sigmoidostomy. In a few cases where the growth is in the centre of the sigmoid loop, lateral anastomosis between the two limbs of the loop will be suitable. Colotomy is the only available method when the growth is situated too low down in the sigmoid to allow of the ileum being anastomosed below it. It is also not safe to perform short- circuiting if obstruction is present at the time of operation, and this must often be the case. Colotomy must then be done ; or, preferably, a faecal fistula established above the growth, and a short-circuiting operation performed after the obstruction has been relieved, the faecal fistula being then allowed to close. In conclusion, it must be borne in mind, when a tumour of the colon is discovered, that it may be a case of hyperplastic tuber- culosis, and not cancer. Short of cutting open the tumour it is impossible to make a certain diagnosis between these two condi- tions, and in view of this possibiUty the tumour should either be excised or short-circuited if it can be managed ; for if the case is one of tubercle, recovery will very probably follow either of these operations ; whereas, if the surgeon closes the abdomen under the impression that he is dealing with a hopeless case of cancer, the patient will almost certainly die. 276 Chapter XIX. TRAUMATISM. The colon is so deeply situated in the abdominal cavity, and so well protected, that, apart from gross injury involving the whole or greater part of the abdominal viscera, it is but rarely the seat of severe traumatism. Rupture of the colon from direct violence is a very rare con- dition, and but few instances have been recorded. Out of 292 cases of abdominal injuries collected by Mr. Makins at St. Thomas' Hospital in nine years, the intestine was injured in 22, and in only 5 of these was the colon involved. It requires a very serious traumatism to rupture the colon, and in most of the cases the cause is either a crush such as will result from being run over by a heavy vehicle, or a severe blow such as the kick in the abdomen by a horse. One would suppose that the transverse colon, where it passes across the spinal column, would be the part most likely to be thus ruptured. The cases I have been able to collect are too few to warrant any conclusions on this point, but at least it may be stated that the transverse colon is not alone affected, for in two instances the ascending colon was ruptured as the result of direct traumatism of the abdomen. The nature of the injury of the colon varies considerably, from a complete tear or tears involving the whole lumen of the bowel, to a minute opening. In some, the colon was apparently not ruptured at the time of the accident, but was so damaged that it gave way in one or more places later. In a case recorded by Mr. Battle, the rupture occurred at the splenic flexure as the result of the patient being run over, and the tear was apparently mainly post-peritoneal. Rupture of the colon from within must be an extremely rare TRAUMATISM 277 condition, but I have been able to find two instances. In both the nature of the accident was similar. In one, the patient, a man, fell off a step-ladder on to an umbrella stand, and the handle of an umbrella entered the rectum and was broken off. It found its way into the transverse colon and perforated the bowel- wall. The umbrella handle, which measured 7 inches in length, was subsequently removed by operation from the trans- verse colon, and the patient made a good recovery. In the other case, the patient feU upon a broom handle, which passed up the rectum and perforated the bowel just above the recto-sigmoidal junction. The patient was operated on a few hours later, when a large rent was found in the anterior wall of the bowel. It was closed with stitches, and the patient recovered. Rupture of the colon from indirect violence must be extremely rare, but McCaskey has recorded a case in which the splenic flexure ruptured as the result of violent peristalsis above a stricture of the sigmoid flexure. As a rule, in a rupture of the colon the injury is compHcated by severe bruising or laceration of the neighbouring bowel, or of the mesentery. Surgical emphysema, owing to the escape of intestinal gas from the bowel into the subperitoneal areolar tissue, has been present in some of the cases. Treatment. If the severity and nature of the injury can be diagnosed, there should be no hesitation in resorting to immediate operation. The indications for operating are the same as for perforation of the bowel in any part. It will be but seldom that the exact nature and site of the lesion can be diagnosed. As a rule, all that can be known is that a serious injury to some portion of the bowel has occurred. Under these circumstances a median incision will be indicated, so as to allow the whole of the bowel to be examined. When the rent has been discovered, it will depend upon the nature of the lesion as to what procedure is adopted. If there is only a small rent, and the neighbouring bowel- wall is not seriously damaged, simple closure of the tear by Lembert sutures is all that is necessary, combined with careful cleansing of the peritoneal cavity, drainage being provided for if any serious soiUng has occurred. If the colon is completely torn across, or if the bowe]- wall has been so damaged as to negative any hope of its recovery, 278 TRAUMATISM resection of the damaged portion will have to be performed. The bowel may either be united end-to-end by suture, or the ends can be closed and the bowel united by lateral anastomosis. In the case of the transverse colon or sigmoid flexure, the ends of the colon can be brought out of the abdomen after resection and sutured to the skin so as to form an artificial anus ; the spur may be destroyed later on and the opening closed b}^ plastic operation, or an anastomosis performed at some later period when the patient has recovered from the shock of the injury. The exact character of the operative procedure must, how- ever, vary in different cases according to the nature of the injury and the condition of the patient. Considering the serious nature of the injurjdn these cases, and the difficulty of making a correct diagnosis before peritonitis has developed, the results of operation appear most encouraging. Thus, out of six cases of rupture of the colon submitted to operation, four recovered and two died, while of the cases not operated upon both died. The following curious case of rupture of the mesosigmoid from direct violence seems worth recording : — Case. — The patient was a man, aged 20, under the care of Dr. Ross in the German Hospital, New York. He was struck in the abdomen during a fight. Shortly afterwards severe pain in the abdomen induced him to come into the hospital. On admis- sion a mass could be felt in the right iliac fossa, and he was much collapsed. The abdominal muscles were rigid. Immediate operation was decided upon. An intravenous injection was given prior to operation, as the patient was in bad condition. On opening the peritoneum much free blood escaped. There was no rupture of the intestine, but an extensive haemorrhage between the layers of the mesentery, and the outer layer of the mesosigmoid was denuded of its serous coat for about 4 inches. There was also much blood behind the peritoneum. The serous coat of the mesosigmoid was sutured with fine silk. Two pieces of gauze were packed in to stop the oozing from the mesenteric wound. A faecal fistula formed on the eighth day from the pressure of the gauze upon a portion of badly nourished bowel. The fistula healed spon- taneously on the sixteenth day. The patient left the hospital well on the forty-fifth day, but returned six days later with pain in the abdomen and vomiting. He also stated that his bowels had not been open for twenty-four hours. He was supposed to be suffering TRAUMATISM 279 from chronic obstruction, and it was thought advisable to operate. At the second operation the old scar was excised. The sigmoid and small bowel were found to be matted together in numerous places. The adhesions were broken up, but in doing so the serous coat was damaged in several places, and in one place an opening was made in the bowel which had to be sewn up. The patient died on the third day after the second operation. The cause of death was general peritonitis. Chapter XX COLOTOMY. The object of this operation is to make an artificial outlet for the faeces, either temporarily or permanently, by establishing an opening between the skin surface and some portion of the colon. In the pre-Listerian days, when surgeons were afraid to open the peritoneal cavity, lumbar colotomy was always performed when it was necessary to make an artificial anus ; but since the introduction of antiseptic methods it has fallen into disuse, and has now with a few exceptions been entirely replaced by inguinal trans-peritoneal colotomy. This is an operation which at the present day is practically unattended by any mortality. The following is the only instance I have met with in which a fatal result was caused by the operation : — Case. — I was called one day to see an elderly man who had symptoms of intestinal obstruction. He was suffering from inoperable cancer of the rectum, and five days previously a left inguinal colotomy had been performed by another surgeon. The colotomy had been done by the stitch method, and appeared quite satisfactory ; but although the bowel had been opened and aperients given, there had been no action of the bowels, and symptoms of acute obstruction had developed. A csecostomy was done, but the patient died before the operation could be com- pleted. Post mortem it was discovered, on opening the abdomen in the middle line, that a portion of the great omentum had been caught up in the colotomy stitch in such a way that it dragged upon the centre of the transverse colon, and had formed a sharp kink which entirely obstructed the bowel. We must, of course, not confuse the mortality due to diseased conditions for which the operation is performed with that due to the operation itself. In many cases it is performed in an attempt to save the life of a patient who is in extremis, and in such cases it not infrequently happens that the patient dies in GOLOTOMY 2«I spite of the operation. Colotom\' should in skilled hands be almost free from risk. The usual method of performing colotomy at the present day is to make a small vertical incision through the abdominal wall about half way between the umbilicus and the left anterior superior spine of the ilium. Through this opening a loop of sigmoid is pulled out. The bowel is then pulled down until that portion nearest to the descending colon which can be made to reach the opening is found, and this portion is used to form Fiq. 68. — Methcd of performing inguinal colotomy. using a clip to form the spur. the colotomy. A spur is now made, either by means of a mattress stitch passed through the mesosigmoid, or preferabh* by a glass rod or a clip which is passed through the mesosigmoid and allowed to rest on the skin on each side of the wound. A stitch is passed through the skin at the end of the incision, and through the anterior longitudinal muscle band. Such a stitch should be inserted at both ends of the wound, to anchor the bowel and prevent smy further prolapse. Unless a large incision has been made, one stitch at each end should be 282 COLOTOMY sufficient. If there are an}/ large appendices epiploicae thev should be ligatured and removed. In many text-books the position for the incision is given as the junction of the middle and outer thirds of a line between the umbilicus and the left anterior superior spine. While this incision is directl}^ over the colon, it has the disadvantage that afterwards, when a cup has to be fitted over the colotomy opening, the edge of the cup tends to ride up on the iliac crest as the patient walks or moves, and this results in leakage and discomfort. I prefer to make the incision much nearer the middle of the abdomen, and far enough away from the pubes and iliac crest to Fig. 69. — Author's incision for inguinal colotomy. insure that any apparatus afterwards fitted will rest entirely on the abdominal wall. The incision is made through the outer fibres of the rectus muscle, and the bowel pulled out between the muscle fibres. This assists considerably in giving subsequent control. It is important to make the abdominal wound small, as the resulting control is better. An incision one-and-a-half inches long is sufficient. The bowel is usually opened on the second day after operation. For this purpose no anaesthetic is required, the bowel being quite insensitive. A small transverse cut should be made with a pair of scissors in such a wa}- as to partly GOLOTOMY 283 divide the bowel. A transverse incision is better than a longi- tudinal one, because the bleeding is less. If it is necessary to open the bowel at once, a Paul's tube should be tied into it to prevent soiling of the wound. Some six or eight days later the bowel is completeh' di\'ided by cutting it across. The whole bowel should be completely divided by inserting one blade of the scissors along the track of the glass rod or clip, and the other outside the bowel, cutting through all the intervening tissue. At the same time, any bowel projecting above the skin level should be trimmed off close to the skin. Xo anaesthetic is necessary. One of the chief difficulties in securing control over the opening after such an operation is the lack of an}^ sensation which can warn the patient that the bowel is acting. As I have shown in discussing the physiology of the colon, a certain amount of sensation at the opening usually develops in course of time. In such cases the sensory nerves doubtless grow into the mucous membrane from the skin, and it is therefore important to see that there is not a redundant fold of mucosa outside the skin, as the mucous membrane never becomes sensitive for more than a short distance from the skin edge (see diagrams, page 16). Several new methods of performing colotomy have been devised with the object of giving the patient better control over the opening. The earliest of these consisted in giving a twist to the bowel above the opening, or in stricturing it by means of a ligature ; these, however, did not prove satisfactory, and have been abandoned. Witzel was the first to suggest making a valvular opening in the abdominal wall. This was done as follows : A loop of sigmoid colon was first brought out through the usual colotomy incision, and another smaller incision was made below the pelvic brim. A space was then opened up between these two incisions by separating the internal and external oblique muscles, and the loop of bowel was dragged through this space and stitched to the skin at the lower opening, the upper opening being completely closed. Bailey's modification of this method consists in opening up a space between the skin and external oblique muscle, and bringing the colon out through an incision just above Poupart's ligament. Tuttle describes a modification of these methods as follows : The ordinary incision is made, and a loop of colon pulled out. This should come outside for at least two inches. The lower 284 COLOTOMY fibres of the external oblique are then pulled downward, and the internal obhque is spht laterally to the extent of about | of an inch. A canal is next made between the skin and external obhque, downward for 2 inches, and made to open through the skin just above Poupart's hgament. This canal should be large enough to admit the loop of colon easily. By means of a tape and dressing-forceps the end of the loop of bowel is drawn through the lateral sHt in the external obhque, and downward through the canal outside this muscle until it emerges at the skin opening. It is held here by stitches or a glass rod, and the abdominal wound is closed in layers (see Fig. 70). It is claimed for these methods that, by wearing a truss which presses upon the skin over the bowel where it passes sub- cutaneously, the patient obtains complete control over both gas and faeces. The opening, however, is placed in a very incon- venient position in the fold of the groin, and the author's ex- perience of these methods has been that the control is httle if any better than that obtained bj^ bringing the bowel straight through the abdominal wall. The valvular opening is good at first, but in a ver\' short time the tension of the bowel straightens out the canal, and if one puts one's finger into the opening it is found to pass straight through the abdominal wall, and all GOLOTOMY 285 resemblance to a valve has disappeared. The author believes that the best control is obtained by making a small incision and bringing the bowel out through the split 'fibres of the rectus muscle. When the patient is standing or walking the rectus will be contracted, and will effectually close the opening and prevent leakage. Moreover, at any time, by contracting his recti, he can to a considerable extent prevent leakage from the opening. I have found that patients with this form of colotomy quickly obtain most excellent control, and are able, with little or no trouble, to keep themselves clean. Fig. 71. — Diagram to show the incision for lumbar colotomy. The incision is made with its centre on a line drawn from the tip of the last rib to a point half-an-inch behind the centre of the crest of the ileum. Lumbar ColotomY. — This, formerly the favourite operation, is now only employed in special cases : as, for instance, when the colon cannot for some reason be brought up to the abdominal wall, and inguinal colotomy is therefore impossible. Right lumbar colotomy is also sometimes performed in place of caecostomy, as the control afterwards is better owing to the more solid nature of the faeces in the ascending colon. The patient is laid upon his side, with a firm cushion or sand- bag under the loin, in order to flex the trunk sideways and open out the space between the last rib and the ihac crest. The position of the colon is indicated by a vertical fine drawn upwards 286 COLOTOMY from a point half-an-inch behind the mid-point between the anterior and posterior superior spines of the ilium. An oblique incision is made, with its centre over this line, and midway between the last rib and the crest of the ilium. The incision should be about 3 inches long. The anterior edge of the quadratus lumborum should be exposed in the back of the incision and, if necessary, parth' divided. The wound is then opened until the transversalis fascia is met with. On dividing this, the cellular tissue and fat are seen, and when these are separated, the back of the colon will be exposed in the bottom of the wound. The colon is pulled up into the wound and fixed to the skin by sutures all round, an oval surface of colon being left exposed. If it should be necessary to open the colon at once, a Paul's tube or one of the author's rubber tubes should be tied in, otherwise the colon is opened by a longitudinal incision at the end of twent3--four hours. If the colon is found to have a mesentery, and it is not possible to expose it extraperitoneally, the peritoneum should be opened in front of the colon and the bowel brought out in the same way as in performing inguinal colotomy. The colon is more likely to have a mesentery on the right than on the left side. Control over the Opening after Colotomy. — Very pessimistic opinions are generally expressed as regards the comfort of patients upon whom colotomy has been performed. With the object of ascertaining whether such a view is justified I investi- gated the after-histories of several of the patients upon whom I had performed inguinal colotomy ; I found that in old people, especialh' of the poorer classes, who have but few facihties for keeping themseh'es clean, there is usually no control over the discharge from the opening. This is more particularly the case with men, and with patients suffering from an exhausting illness, such as cancer of the rectum. Where, however, the patient was of a better class, and was willing and able to take a little trouble, very good control over the opening was usually obtained ; so that I found many patients able to live an ordinary Hfe, mixing wdth other people and attending to their business without difficulty and without others knowing of their disabilit\-. Some patients had quite a surprising amount of control. One was a man of 33, with a left inguinal colotomj^ which had been made o\'er a year previously. After the first four months GOLOTOMY 287 he was always able to tell when the bowels were about to act, and the opening did not cause him the slightest trouble except on one occasion after he had eaten something which disagreed with him. He attended to his business and played football for his local team. Another patient was a gentleman who lived in the country and hunted several times a week ; the colotomy had been done some years previously. One patient, a stevedore at the London Docks, who had a permanent colotomy, was 62 years of age, and returned to his employment after the operation and worked his eight hours a day. He assured me that the colotomy opening did not interfere with his work, and he was quite able to keep himself clean. The best control was obtained where there was a small opening without prolapse of the mucous membrane, and when the patient wore a celluloid cup over the opening. The use of a plug fitting into the opening prevents any sen- sation being acquired which will warn the patient of the necessity of attention. A case is recorded by Dr. Mitchell of a woman who was suc- cessfully delivered of a child ten months after colotomy had been performed. Colotomy by Paul's Method. — This is frequently the best and safest method of dealing with the bowel after resection of part of the colon. The colon is exposed and brought out of the wound in the same way as in performing inguinal colotom}-. The wound having been first shut off by gauze packing, the colon is divided, and a Paul's glass tube of suitable size tied into either end by a silk ligature. The two portions of colon are then sewn together side by side, for about two inches of their length, with silk sutures, with the object of ensuring the walls being in contact later, when the enterotome is used (See Fig. 72). The tubes come away in about a week, and some three weeks later the spur is destroyed by means of an enterotome (see page 292). After the spur has been destroyed, the continuity of the bowel is re-established, but a facal fistula still remains, which an course of time usually closes of itself ; but it may be many months before this occurs, and it is better as a rule to close it by operation. If the spur has been well divided, all that is necessary is to dissect the mucous membrane off the skin and sew it up. 288 COLOTOMY There is no necessity to open the peritoneal cavity, and the risk of the operation is therefore shght. This method of dealing with the bowel after resection of the colon for stenosis or tumour has the disadvantage that the patient has the discomforts of a faecal fistula for some time, and that a second operation is rendered necessary. On the other hand, there can be no question but that it is by far the safest method. It is practically unattended by any mortality, while immediate end-to-end union is followed by a high death-rate. Cases in \A^hich it is impossible to perform Colotomy, — At times this operation has to be abandoned, either because Fig. 72. — Paul's method of performing colotomy. the colon cannot be found, or because it cannot be made to reach the skin. Such cases are of considerable interest, as they cause great difficulty to the surgeon. They are now less common than in the days when lumbar colotomy was the usual operation. Thus a case is recorded by Lockwood, in which right lumbar colotomy could not be performed because the caecum and ascend- ing colon lay on the left side of the abdomen. With inguinal colotomy, abnormalities of the colon are less likely to lead to inability to perform the operation, though they may cause considerable difficulty. The sigmoid flexure being situated on the right side of the COLOTOMY 289 abdomen instead of the left may create difBculty, and this condition is not very uncommon. I have met with one case in which the operation had to be abandoned owing to the sigmoid being fixed in the right ihac fossa. The bowel could not be found on the left side, and on making an incision on the right, it was found to be impossible to bring the sigmoid into the wound. In two cases the operation was impossible from the fact that the entire colon was fixed and immovable. In both these cases there was hyperplastic tuberculosis of the colon, and caecostomy had to be done. Caecostomy. — This operation is performed when it is not possible to perform colotomy, or when a colotomy opening will not be above the seat of obstruction. It is also sometimes done to deflect the faecal current from the colon in cases of ulcerative colitis. The csecum is exposed through an oblique incision, the centre of which lies over a point half way between the umbilicus and the right anterior superior spine of the ileum. The anterior wall of the caecum is drawn out of the wound and sewn to the skin and aponeurosis all round the edges of the wound. The stitches should take up the peritoneal and muscular coats only, and when they are all inserted the peritoneal cavity should be completely shut off, and an oval area of the caecal wall about 1^ in. long should alone remain exposed. Two sutures to act as guides should be inserted into the caecal wall, and two days later the caecum is opened by cutting between these guide sutures with a knife. Another method of performing caecostomy, and a preferable one if the caecum has to be opened at once, is to enclose a small circular area of the caecal wall about ^ in. in diameter in a purse-string suture. This portion of the caecal wall is then held up by an assistant, and a small incision into the cfficum is made in the centre of the circular area ; through this one end of a Paul's tube is pushed, and the purse-string suture is then tied firmly on to the tube. The caecal wall is stitched into the wound and the latter closed, leaving the Paul's tube projecting. Owing to the liquid nature of the contents of the caecum, the control over this opening is very unsatisfactory, and the sur- rounding skin often becomes sore and excoriated. This may to some extent be prevented by keeping the parts well greased with lanolin. 19 290 CLOSURE OF AN CLOSURE OF A F^CAL FISTULA OR ARTIFICIAL ANUS BY OPERATION. A Faecal Fistula. — The surgeon may be called upon to close a faecal fistula which has resulted from disease of the colon, or which he or some other surgeon has made, but which is no longer necessar\-. Operations for closing faecal fistulae in the colon are often ver\- difficult, and have not infrequently been attended by a fatal result. Ver\- careful consideration is advisable before attempting an ■operation of this nature ; it is not justifiable to risk the patient's life for what in man\- cases is onh- an inconvenience. Providing the normal channel to the anus is patent and not seriouslv obstructed, most faecal fistulae will close spontaneously if given sufficient time. The most difficult fistulae to close are those which communicate with the csecum. The reasons for this are probabh' the fluid nature of the contents of the caecum, and more especialh' the pressure to which any join in the caecal wall will be subjected owing to antiperistalsis in the right side of the colon. In some cases several operations have had to be performed before a faecal fistula in the caecum could be made to close. The following table, compiled by the author, shows the results of 36 operations undertaken for this piu"pose or the closure of an artificial anus : — Table of the Results of Operatioxs for the Closure of F^cal Fistul.^. Opening closed successfully . . . . . . 16 First operation failed to close the opening . . 9 Repeated operations failed . . . . . . 6 Patient died as a result of the operation . . 5 36 One of the chief difficulties in operating to close a faecal fistula is the great danger of the wound becoming infected during the operation. The best plan is to disinfect the fistula, either with cautery or with some powerful antiseptic, and then to dissect out a piece of skin containing the fistula and the entire fistula itself down to the colon ; the fistula can then be cut off, and the stump invaginated into the bowel %ATith a purse-string suture (this method is only apphcable to ver^- small fistulae or those leading into the caecum). Another method is to excise the portion of bowel containing the fistula and carefully close the ARTIFICIAL ANUS 291 wound in the bowel with a double row of sutures, the first row taking up all the coats, and the second the peritoneal and muscular coats onl}-. If this is likely to cause serious narrowing of the bowel lumen, the wound in the bowel should be sewn up transversely instead of longitudinally. Still another plan is to resect that portion of the colon containing the fistula and anastomose the ends. This, however, is attended with much more risk than the previous methods. The success of the operation in any case depends upon very careful asepsis and close stitching. Where the fistula is associated with stenosis of the colon, there are three methods which have been used for getting rid of it : — 1. The portion of bowel with which the fistula communicates may be resected, together with the stenosis or tumour. 2. It may be short-circuited. 3. It may be excluded, either partially or totally. If resection is decided upon, it is advisable to perform a preliminary short-circuiting operation ; this can be done without interfering with the fistula, and therefore without danger of infecting the peritoneum. Short-circuiting will often result in closure of the faecal fistula. Both partial and total exclusion will almost certainly fail to do this, but they will very materially diminish the discharge there- from, and greatly increase the patient's comfort. Artificial Anus. — The closure of a colotomy opening will depend very largely upon the manner in which the original operation was performed. When a temporary colotomy opening has been made by the method described on page 281, with a .glass rod or clip, and the bowel has not been completely divided, but only opened on its anterior aspect, it can be quite easily closed without opening the peritoneal cavity. The cut edges of the wound in the colon are first dissected free, and freshened by cutting away the extreme edges. They are then brought back into position, and the wound in the colon is closed by suturing the edges carefully together, a second row of sutures being inserted over the first to make all tight. The colon, being now closed again, is dissected away from its attachments to the abdominal wall until the peritoneum is reached. This is not opened, but is stripped from the underside of the abdominal waU for about an inch all round the opening, or sufficiently far to give the colon a free lumen without kinking. Lastly, the 292 CLOSURE OF AN wound in the abdominal wall is closed over the colon (see Fig. 73). The portion of colon which originally formed the colotomy is thus left in the subperitoneal tissue, and, if leakage should occur, it will be externally. This method can also be used when the gut has been completely divided. The ends of the colon are freshened, then anastomosed by suture, and lastly buried in the subperitoneal tissue. Fig. 73. — Method of closing a colotomy opening extra-peritoneally It is perhaps unnecessary to point out that, previous to any such operation, the colon should be well cleared by aperients, and steps taken afterwards to prevent any but quite liquid faeces passing through it for the next ten days. Another plan of closing a colotomy opening without exposing the peritoneal cavity is that used after colotomy by Paul's method. This is also applicable to a colotomy opening made in the ordinary manner. Fi^. 74. — Enterotorae for destroying the spur. The spur between the two portions of bowel is first destroyed, so as to make the upper and lower Umbs of the colon communicate freely below the skin level. This is done by means of an enterotome ; or a chp forceps with long blades will do equalh' well. The surgeon places his first and second lingers into the two ARTIFICIAL ANUS 293 openings of the colon, and assures himself that there is nothing but the respective walls of the two portions of colon lying between his fingers. The two blades of the enterotome are then inserted along his fingers so that one blade hes in each portion of bowel, and the instrument is closed so as to grip tightly the spur over a distance of about i-| to 2 inches. The instrument having been firmly fixed in position, and the handles supported by dressings, it is left until it comes loose owing to the destruction of the spur by sloughing. The blades of the instrument are very apt to slip up the spur, and it may be necessary to re-apply it several times. If any of the mesentery is included between the blades, and sometimes when it is not, there is a considerable amount of pain while the enterotome is cutting its way through, and for this it will be necessary to give morphia. It takes as a rule, from two to five days to destroy the spur and join up the two portions of bowel. If the bowel is examined after the enterotome has become loose, it will be found (.hat there is some swelling of the edges of the opening, but this dis- appears in a few days. The faeces will at once begin to pass in part by the normal channel, and steps can then be taken to close the skin opening. This necessitates an anaesthetic. The edges of the mucous membrane should be dissected loose from the skin and muscles, turned in, and stitched together. The skin, and as much of the deep parts as possible, should then be brought together above, so as to close the skin opening. If the spur is freely divided with the enterotome, the external opening will close itself in time ; but this may take many months. This is a very safe, though rather tedious, method of closing a colotomy opening. 294 Chapter XXI. APPENDICOSTOMY AND VALVULAR CMCOSTOMY. APPENDICOSTOMY. This operation was first performed by Weir, of America, in a case of ulcerative colitis. It was the outcome of a suggestion by Dr. Hale White in 1S95, that a rightinguinal colotomy should be done in cases of intractable colitis. Weir's original operation proved extraordinarily successful. The patient rapidly recovered as the result of daily irrigation of the colon, whereas previously the only satisfactory results' in similar cases had been obtained by establishing an artificial anus on the right side, a procedure almost as objectionable as the disease. Weir's first operation was performed in 1902, and since then it has been done in a considerable number of cases, one of the first surgeons to draw attention to the operation in England being the late Mr. Keetley. It forms a satisfactory and safe method of enabling the whole colon to be irrigated with any desired solution, and at the same time does not leave the patient with an offensive and leaking opening. As originally performed by Weir, the operation consisted of bringing the end of the appendix out of a wound in the abdomen and stitching it to the["skin. The caecum was not drawn up to the'^abdominal wall, and consequently it was possible for a loop of intestine to become strangulated around it and also, if inflam- mation of the appendix should occur, the peritoneal cavity might become infected. These objections, however, were soon realized and the c^cum pulled up so that the entire appendix lay in the thickness of the abdominal wall. The operation is performed as follows : An oblique incision is made over McBurney's point in the same way as in the ordinary operation for appendicectomy. The incision need only be a short one, and an inch and a half is often sufficient. The peritoneal APPENDICOSTOMY 295 cavity is opened and the appendix found. The meso-appendix is then divided close to the appendix for from -| to i inch, depending upon the length of the appendix ; but in any case care should be taken not to sever the artery of the appendix. If it is cut, there is risk of the appendix sloughing through lack of adequate blood-supply. The artery should be looked for, and the meso- appendix only divided up to it, and no farther. The appendix is then brought out of the wound and pulled up until the caecal Weill comes well up against the parietal peritoneum. One or two catgut sutures may be inserted, so as to anchor the caecal wall to the fascia and parietal peritoneum. Two or three stitches will then suffice to close the remainder of the wound. Lastly, a single stitch should be passed through the wall of the appendix, so that it can be anchored to the skin and prevented ^''S- 75- — I'iagram to show the method of fixing the caecum and appendi.x to the abdominal wall. from retracting. The dressings are then applied and the opera- tion is finished. In appl3ang the dressings, a roU of gauze should be placed on each side of the appendix to prevent the blood-suppl}' being damaged by the pressure of the bandage. If there is any doubt about the patency of the appendix, it should be opened at once, but if it is large and healthy it may be left, and opened two or three days later. In performing the operation, and especially in closing the wound, the importance of preserving the blood-supply of the appendix should be borne in mind. About two or three days later the dressings should be removed, and the appendix cut off about J to J an inch from the skin. It is better not to cut it flush with the skin. An appendicostomy catheter (No. 7 or No. 10) can then be passed into the caecum 2q6 APPENDICOSTOMY through the stump of the appendix, and irrigation commenced. Later, any mucous membrane that projects above the skin level can be cut away so as to leave a neat opening. The above seems to be the best procedure in view of leaving as good an opening as possible. If the appendix is cut off at or soon after the operation, a certain amount of superficial suppuration in the. wound will probably occur, and this often leads to some stricture at the orifice. The catheter should only be inserted in the canal for irrigation. If it is left in and happens to be rather a tight iit, the whole appendix may slough, owing to its presence interfering with the blood-supply, which, as the appendix is a vestigial organ, is often none too good. Tuttle advises that at the end of thirty-six hours a catheter should be passed into the caecum, and a ligature tied tightly round the appendix on to the catheter and left in position till it has amputated the appendix. As has already been mentioned; Full Size End Pig. 76. — Appendicostomy catheter. however, the continued presence of the catheter is liable to cause sloughing of the stump. The operation can be performed in a very short time, and with the minimum of exposure of the abdominal cavity. It is practically free from any serious risk, and can be performed on patients whose general condition is bad and would contra- indicate any more serious operation. For these reasons it is admirably suited to such cases as ulcerative colitis and other suitable forms of colitis. The results obtained from irrigation of the colon through an appendicostomy wound are fully considered under the headings of the diseases for which it has been recommended. It may happen that at the operation the appendix is found to be diseased, deformed, or rudimentary : in such cases consider- able modification of the technique will be necessary to deal with it, or it may not be possible to utilize the appendix at all. Under such circumstances it should be removed, and some APPENDICOSTOMY 297 form of valvular ctecostomy, such as is presently described, performed. It may be well to mention here that care should be taken as to the fluid used for irrigation. Considerable absorption occurs in the colon, and it is dangerous to put any fluid or dose of a drug into the colon that cannot safely be put into the stomach. This has not sometimes been sufficiently realized, and I have seen two cases of boracic acid poisoning, with a rash and vomit- ing, result from the use of boracic acid lotion for irrigation, and one case of carbohc acid poisoning from the use of weak lysol solution. I have been able to collect 50 cases in which this operation has been performed, of which nine are my own. A careful anah'sis of these shows that while the operation is practically devoid of any risk as regards Hfe, there are several minor compHcations which may result and cause trouble, though, as I shall be able to show, these may be avoided by care in performing the operation. Six of the patients died, but in no instance was death attributable in any way to the operation. Two died, some months later, of cancer of the colon present at the time of opera- tion. One died of peritonitis — the operation having been done to relieve distention ; one died of miUary tuberculosis some weeks later ; one of ulcerative coHtis, for the rehef of which the operation had been performed, and it was discovered post mortem that the ileum was also ulcerated ; and one died from another operation performed some time later. Minor complications occurred in nine cases. In one, the opening could not be kept open more than four weeks. In six cases the appendix sloughed : in four of these it was due to a catheter being left in the appendix ; in the other two it was apparently due to the blood-supply having been damaged at the operation. In two of the cases in which the appendix sloughed, the opening became obliterated ; but in the other three it was kept open b}^ means of a rubber plug, and a useful opening resulted. In two cases in which the appendix was cut off at the operation , the stump retracted inside the wound, resulting in suppuration and subsequent difficulty in inserting the catheter. In another case also, suppuration of the wound occurred, apparently from the same cause. In three cases the appendix at the operation was found to be diseased and its lumen obliterated. In each 298 APPENDIGOSTOMY of these a catheter was passed into the caecum through a small opening, and part of it was then buried in the caecal wall with Lembert sutures, the other end being brought out through the abdominal wall. In one of my cases the appendix was found to be only an inch long and quite rudimentary, having a patent lumen for only half an inch from the caecum. The patient was a stout woman with an abdominal wall four inches thick. The caecum was stitched to the parietal peritoneum, and the end of the appendix cut off. A catheter was then passed through the short stump into the caecum, and a hgature tied tightly round the stump on to the catheter, the other end of the catheter being brought out of the abdomen (see Fig. 77). This case did very well, but the catheter or a solid rubber plug has to be left in the canal to prevent its closing, as the walls consist only of fibrous tissue. In another case, I had to adopt the same procedure because the appendix had no lumen for three-quarters of its extent. In only one case was there any leakage of faecal material. The patient was a woman, and the operation had been i)erformed for chronic colitis. - There was considerable leakage from the opening. On enquiry I found that the surgeon who performed the operation divided the whole of the meso-appendix, and in consequence the entire appendix sloughed and came awa}^ The result was therefore, in reality, a faecal fistula communica- ting with the caecum, and not an appendicostomy opening. The results of appendicostomy as regards the operation itself are most satisfactory. After the wound has healed the opening APPENDICOSTOMY 299 is barely noticeable, appearing merely as a small pink spot on the abdominal wall (see Fig. 78). No leakage at all occurs through the opening when the catheter is withdrawn, or at least lias not in any of the cases I have seen. In one, I injected sufficient water into the colon to cause marked distention of the abdomen, and on removing the catheter there was no leakage from the opening. Neither flatus nor fseces escape, and the presence of the opening causes the patient no inconvenience whatever. Most patients find it quite unnecessary to wear anvthing over it. /'/["". 78. — Photograph .showing the appearance of an appendicostomj' opening three j"ears after operation. The opening is still patent. {Au!/ii>?-s case.) Should it be necessary to close the opening, all that is re- quired is a touch with the cautery or the application of a Httle nitric acid to the mucous Uning of the opening, the wound readily healing in a few days. It is better to keep it open till all possibility of its being required is gone, and as it causes no inconvenience, this can readilv be done. 300 C^COSTOMY FOR IRRIGATION Irrigation through the opening can be carried out easily by the patient, and he is not prevented from hving his usual Ufe or from going into the society of others in any way. Several patients assured me that the opening caused no inconvenience, and one (a labouring man) said that he found it saved him time, as he was always certain of being able to empty his bowel in three or four minutes. All that is necessary to irrigate the bowel is to pass a catheter into the opening and attach a Higginson's sjn-inge to the other Fig. 79. — Diagram to show method of making a valvular caecostomy in cases where the appendix cannot be utilized. end. The fluid is then pumped into the caecum in a few minutes, and allowed to run out at the anus. If oil is used it is best put in with a glass syringe, as it flows too slowly through a funnel. CAECOSTOMY FOR IRRIGATION OF THE COLON. In cases where the appendix cannot be used, this operation, or some modification of it, can be performed. A small opening is made in the wall of the csecum just large OF THE COLON 301 enough to admit the end of a No. 10 catheter (of soft rubber). The end of the catheter is passed through this hole for about f inch. A series of Lembert sutures are then commenced, well beyond the hole, and continued over the catheter for about I J inches. These should be so placed that, when they are tied up, the catheter for about an inch will be buried in the wall of the caecum. The caecal wall where the catheter passes through is then anchored firmly to the bottom of the wound, the base of the catheter is brought out of the wound, and the remainder closed. This makes a very good opening and does not leak, but it is necessary for a small rubber plug to be worn to prevent the opening from cicatrizing up. 302 Chapter XXII. RESECTION AND ANASTOMOSIS OF THE COLON. THE PREPARATION OF THE PATIENT FOR AN OPERATION UPON THE COLON. One of the most important factors in obtaining successful results from operations upon the colon is the preparation of the patient. When we have to operate for acute obstruction, or other urgent symptoms due to disease in the colon, it is often impossible to have the patient properly prepared. Under such circumstances immediate operation is of more importance than any other factor, and the advantages which will result from careful preparation have to be sacrificed. For this reason, most operations performed for urgent obstructive symptoms are of a simple nature, usually some form of colotom}^ In most cases in which an anastomosis or resection has to be performed there is no great urgency, and careful preparation of the patient is possible. This is of almost as much importance as the skill of the operator ; and the best results are undoubtedl}' obtained by surgeons who pay most attention to this part of the treatment. It is not sufficient for the preparation to be left to the nurse, with a few brief directions ; the surgeon should himself see that the preparatory treatment is carefully and efficiently carried out. A week, or even longer, is not too much to devote to getting the patient ready for operation if an anastomosis is to be performed. There are two objects to be aimed at : first, that the colon shall at the time of operation be as nearl}^ as possible empty ; and second, that its contents shall be rendered as far as possible aseptic. It is, of course, not possible to render the interior of the colon aseptic, but much may be done to rid it of pathogenic bacteria, and to lower the virulence of those that remain. The bowel should first of all be well cleared by means of a purge, and for this purpose nothing is better than a dose of castor oil (from a half to one ounce) . This may with advantage PREPARATION OF PATIENT 303 be given a week before the operation. After this, the bowels should be kept acting daily by some mild aperient, such as a small dose of magnesia or cascara. The patient should not be restricted as regards his diet, but be instructed to eat onh' plain cooked food, and to avoid vegetables, fruit, or other substances which will leave an indigestible residue. The teeth should be examined, and if carious or otherwise unhealthy, the patient should go to a dentist and have them put right or extracted. An antiseptic mouth-wash should in any case be ordered twice daily to ensure that the mouth is as clean as possible. There are several ways in which we can advantageously modifv the number and variet\' of the bacteria in the colon. We can give intestinal antiseptics by the mouth, such as hquor hydrarg. perchlor. 3], salol gr. x, or beta-naphthol gr. x, three times daily. A more recent and more efficient method of purify- ing the colon is b}- the use of the lactic acid ferment. This acts by introducing into the intestine a harmless micro-organism which will destroy and take the place of those which are already present. The best preparation for the purpose is a fresh culture of the Bulgarian bacillus prepared in a scientific laboratory. Two tablets of the dried culture should be given three times a day in a little sweetened milk. If a fresh laboratory culture is unobtainable, a good brand of soured milk should be given, the dose being about two pints a day. In either case it should be given before meals, and at the end of a day or two the stools should be examined for the bacillus. As soon as the bacillus has appeared in the stools, the dose by the mouth may be cut down by a third. This treatment must be commenced some time before the operation, in order to give the bacillus time to become ■acclimatized to the intestine. Occasionally some degree of digestive disturbance follows the use of the lactic acid bacillus, and in that case the operation should not be performed until it has passed off. The effect of this treatment will be to render the ■colon as nearly aseptic as it is possible to make it.. On the da}- before the operation the patient should be given a smart purge, and the diet be reduced to a light and easily digestible form. On the evening before the operation a soap- and- water enema (two pints) should be given. I always order 15 gr. of pulv. ipecac, comp. or i oz. of mist, catechu comp. to be given at the same time as the enema. Next day, four hours before the operation, an enema of plain warm water 304 PREPARATION OF PATIENT (two pints) should be given. The object of the opium is to arrest peristalsis and to prevent the last enema from inducing peristaltic contractions, as it otherwise will do, and so bringing down more material into the colon. It also has the advantage of helping the patient to sleep the night before the operation, which he will often be unable to do without aid. Whatever opinions surgeons may hold with regard to the use of opium after abdominal operations, there can be no objection to its employment beforehand. I^ig. 80. The patient's abdomen will, of course, be shaved, and a compress applied on the day previous to operation. No food should be given on the morning of the operation, though a cup of weak tea or some other form of fluid may be allowed two or three hours before the time. An exception to this, however, is often advisable in the case of elderly and very young patients. In addition to the above preparatory treatment, I usually give PREPARATION OF PATIENT 305 the patient two or three teaspoonfuls of white vasehne by the mouth for two days before the operation, and continue it after- wards. This makes certain that the fseces will not become consolidated, and that there can only be liquid f feces to pass the line of anastomosis. Petroleum may either be given as white vaseline, to which some flavouring has been added, such as peppermint, or as the liquid petroleum of the Pharmacopoeia. If it is anticipated that the operation will cause shock, I like to give a hypodermic injection of morphia, gr. |-, just before commencing the ansesthetic. This also reduces the amount of anaesthetic required, and renders subsequent vomiting less likely to occur. The patient should be well protected against cold and exposure during the operation, either by a jacket and trousers of gamgee tissue, or by some form of woollen clothing which will not require to be removed. Mr. Arbuthnot Lane's plan for preventing shock in these operations by the subcutaneous infusion of warm saline during and after the operation is excellent. Fig. 80 shows a very useful apparatus, by means of which the saline can be kept at the desired temperature for long periods without constant attention. All that is necessary is to connect the apparatus to a large hypo- dermic needle put under the skin of the axilla, and to keep the tank filled with sterihzed salt solution. The tank should only be raised about a foot above the needle, so that infusion occurs, slowly. The heat is maintained at the required temperature by electricity from the ordinary house supply. RESECTION OF THE COLON. The colon may be resected in part or in whole. The best and easiest method of dealing with a seriously diseased colon is to resect a length containing the diseased area. If the entire colon is so seriously diseased that it is not capable of recovery. it can be completely resected. Whenever possible, that portion which it is proposed to resect should be drawn out of the abdomen, and the abdominal wound and peritoneum carefully protected by gauze packing. The loop of bowel is then, as far as possible, emptied by milking out the contents, and an intestinal clamp is placed on the bowel-wall above and below the points at which it is proposed to divide the gut. The division should always be made through healthy bowel-wall, and well clear of the lesion. In the case of cancer, 20 3o6 RESECTION OF THE COLON the bowel should be divided at least one clear inch from the edges of the growth. In order to be certain of preserving a good blood-supply to the edges of the bowel, the bowel-wall should be divided slighth^ obhquely, the greatest amount of bowel being removed on the side opposite the mesocolon (see Fig. 8i). When the bowel has been divided, and the diseased area removed, the ends of the divided gut should be cleaned with gauze to remove an}^ faecal material. The mucous membrane always prolapses to some extent beyond the other coats, and if anasto- mosis is to be performed, this projecting ring of mucosa should be carefull}^ trimmed off with scissors, so that all the coats are left level. This materially aids accurate apposition of the ends when performing anastomosis. Fig. 8i. — Diagram to show the way in whicli the arteries pass from the arterial arcades to the cohiii wall. Method of Dealing with the Mesocolon. — If resection has been performed for malignant disease, a wedge-shaped portion of the mesocolon should always be removed in one piece with the resected bowel. And it is advisable to remove as far as possible all the lymphatic area immediately draining the growth. The indications for removing this area have been alread}^ discussed fully in Chapter XVIII. When it is not necessary to remove any of the mesocolon, the loose fold left after resection can be turned back on itself and sutured together. All that is necessary is to ensure that no opening or pocket is left which might result in the forn'iation of an internal hernia at a later period. There are various methods of dealing with the bowel after resection, and these, and the indications for each, have been ANASTOMOSIS 307 already discussed. It remains to describe the various methods of anastomosis. ANASTOMOSIS. I shall only describe anastomosis by direct suture, for although there are a great variety of methods depending upon the use of some special apparatus, such as a bobbin or button, these have now been almost entirely discarded in favour of direct suture. This is both better and safer than the use of bobbins, and can be performed as quickly after a little practice. Many successful anastomoses have been performed in the colon with a Murphy's button ; but on the other hand there have been many fatalities which were directly attributable to its use. End-to-end Anastomosis. — This is as a rule only possible in the transverse and pelvic portions of the colon. The results of end- to-end anastomosis are not nearly so satisfactory as in the case of the small intestine. In the latter the operation has quite a low^death-rate ; but in the colon the mortality is nearly 30 per cent. Out of 89 cases of which I have been able to find records, 6o;[recovered and 29 died. Moreover, of those patients who recovered, a number developed a feecal fistula as the result of the operation. End-to-end Anastomosis by Suture. — The colon having been clamped and the diseased portion resected, the two ends of the colon enclosed in the clamps are brought together, so that they lie parallel with one another. The mucous membrane which generally projects from each end of the bowel is then cut off with scissors, so that the mucous membrane is flush with the other bowel coats ; this is advisable, as it enables a much better union to be made. A single mattress suture is next put in, taking up all the coats and joining the two mesenteric borders of the colon. This suture should bring the two mesenteric borders into accurate apposition, and the knot should be tied on the mucous side ; the ends should be left long to act as a guide while the remaining sutures are being passed. A continuous through-and-through suture, taking up all the coats, should next be inserted, starting from the mesenteric border and continued halfway round the bowel. It should then be tied off, and a similar suture started also from the mesenteric "border and carried along the opposite side. After the first turn 20A 3o8 ANASTOMOSIS of this suture has been inserted, the guide suture in the mesenteric border should be cut off. The two continuous sutures are tied together where they meet opposite the mesenteric attachment. Over this first suture Hue a second suture of fine silk should now be inserted uniting the peritoneal coats only. This peri- toneal suture should preferably be inserted in two portions, each going halfway round the bowel ; this minimizes the risk of puckering the bowel. Some surgeons prefer to use silk for the first suture which passes through the mucous membrane, but stout chromicized catgut is perhaps better, for this suture must come out, as it becomes infected from the mucous membrane, and if made of silk, a certain amount of sloughing will accompany its discharge into the bowel. In one instance I examined with the sigmoidoscope the line of union two months after end-to-end anastomosis had been performed in the sigmoid flexure, and was able to see the small ulcers in the mucous membrane all round the bowel where the silk stitch had been, and which were still unhealed. After the ends of the bowel have been joined, the mesosigmoid or mesentery should be repaired so as not to leave a hole through Fig. 83. which small bowel may become strangulated. This is easily managed with a continuous catgut or silk suture. In the case of resection of the csecal end of the colon, if the ileum and colon are to be united end to end, it is necessary first of all to make the two ends of bowel the same size. There are several methods of doing this. The ileum may be cut obliquely and the colon transversely. (See Fig. 82). The ileum may be joined to the colon and then the excess of colon sewn up. (See Fig. 83). ANASTOMOSIS 309 A V-shaped piece of the colon may be cut out on the side opposite the mesenteric attachment, and the V-shaped wound sewn up to make the end of the colon the same size as the ileum. This is Madelung's method. (See Fig. 84.) Doyen has invented an ingenious method by which a sort of artificial ileocaecal valve is formed. The end of the ileum is turned inside out so as to form a cuff. The end of the colon is next reduced till it is the same size as the ileum, the ileum is inserted into it, and the edge of the turned-back cuff sewn to the edge of the colon. (See Fig. 85.) Lateral Anastomosis. — Lateral, instead of end-to-end anasto- mosis, may be performed after resection of the colon or in performing a short-circuiting operation. When the ileum and colon have to be joined it is an easier operation than end-to-end r ^ Fish's- anastomosis. If performed after resection, the two ends of the bowel are first closed. This may be done by sewing up the end and invaginating it, a purse-string suture or a series of Lembert sutures being afterwards inserted to further protect the end. Mr. Lane's method is to put a ligature round the ends of the divided bowel and then invaginate the ligatured end with a purse-string suture. 310 ANASTOMOSIS The two portions of bowel which are to be united are then placed side by side — care being taken to see that peristalsis will occur in the right direction — and joined together side to side for about 2 to 2| inches with a peritoneal stitch taking up the peri- toneal and muscular coats only- This suture is not cut, but left long. An incision in the long axis of the bowel is now made into both portions of bowel, about 2 inches long and close to the line of suture. Any projecting mucous membrane is cut away, and a continuous catgut suture is inserted, taking up all the bowel coats. This is continued right round the openings until they are joined together. Lastly, the peritoneal stitch is con- tinued until it reaches the place where it started, thus forming a double Hne of suture and covering in the first Une. Fig. 86. — Diagram to show the method of inserting guide sutures in performing anastomosis by implantation. When possible it is better to perform the anastomosis before the resection, and also to close the ends of the portion of colon which it is proposed to resect. There is thus considerably less danger of soiUng the peritoneum. In any case, after performing the anastomosis, the edges of the divided mesocolon must be carefully stitched together to avoid leaving any gap or hole through which the small bowel can pass and become strangulated. Lateral Implantation. — This is in some ways preferable to lateral anastomosis, and is favoured by many surgeons. It is much better than end-to-end anastomosis when dealing with the ileum and colon, as it removes the difficulty of the different sizes of the two portions of bowel. If performed after resection, the end of the colon is first stitched up, then an incision of suitable ANASTOMOSIS 311 length is made into the side of the blind end of the colon, and about one to two inches from the end in the long axis of the bowel. A guide suture is then inserted taking up the end of this incision and the middle of the side wall of the ileum, a similar suture being placed on the other side. These ensure the ends of the bowel being stitched together correctly, and are useful in holding the bowel edges in position during suturing. The two edges are then sutured together, taking up all the coats, and last of all a protecting peritoneal line of suture is put in over the first, and the mesentery is stitched together. (See Fig. 86.) Charters Symonds advises using a Murphy's button for lateral implantation. The shght saving of time obtained by this method, however, seems insufficient to compensate for the increased risk of introducing a foreign body into the colon. Ileo-sigmoidostomY. — This may be done either by lateral anastomosis or by implantation of the ileum into the sigmoid flexure. Lane, who has been one of the chief advocates of ileo-sigmoidostomy, advises division of the ileum about 6 inches from the ileocaecal valve, and implantation of the proximal end into the sigmoid flexure by suture. The distal end of the ileum is closed. If the patient is so ill as to render a short operation of para- mount importance, a Murphy's button may be used to form the junction between the ileum and pelvic colon ; but in skilled hands there is little, if any, saving of time to be secured by this method. It is important to carefully stitch together the meso- colon and the divided edge of the mesentery, in order to ensure that no gap is left through which subsequent strangulation might occur. Shortening of the Mesosigmoid. — This operation may be done to prevent the recurrence of a volvulus, and to prevent acute flexures from occurring and causing obstruction or chronic constipation. It may be performed in cases where there is an abnormally long mesosigmoid, and is attended with less risk than the alternative operation of resection of the elongated loop. A series of Lembert sutures are inserted in the long axis of the mesocolon, and parallel with one another. The sutures should all be inserted on one side of the mesentery only, preferably on the outer side, and should take up the peritoneum only, special care being taken to avoid wounding the veins when inserting the sutures. The first row is tied up, then a second row is inserted 312 RESTORING THE BOWEL over these, and so on, until the mesocolon has been sufficiently shortened. As a rule, it is found, after all the sutures have been tied, that a kink has been produced in the colon at either end of the line of sutures. To remedy this, a few more Lembert sutures should be inserted opposite the kinks in such a way as to straighten them out. (See Fig. 32, p. 91.) Colopexy. — This operation is sometimes performed to prevent the reformation of a volvulus, or to cure an abnormal kink or angle in the colon which is causing chronic obstruction. It has also been done in some cases of visceroptosis, and to cure prolapse. The part of the colon which requires anchoring is usually the sigmoid flexure. The bowel is fixed by a series of sutures either to the walls of the iliac fossa, or in some cases to the abdominal wall. When the portion of the bowel has been selected which it is proposed to fix, the peritoneum should be scraped or in part removed, and a corresponding portion of peritoneum removed from that portion of the abdominal wall or iliac fossa to which it is proposed to attach it. It is better to select, if possible, the iliac fossa, as this is fixed, whereas the abdominal wall is con- stantly moving. The selected and prepared portion of colon is next secured to its prepared bed by sutures. These sutures must be very carefully inserted with fine peritoneal needles, care being taken not to perforate the bowel-wall, but at the same time to obtain a good hold. It is also necessary to see that the blood-supply is not interfered with, or the bowel kinked. Colopexy does not appear to be very satisfactory, as in several instances in which it has been performed to prevent the reforma- tion of a volvulus it has failed, and at a subsequent operation the bowel has been found free and with no trace of the previous fixation. METHODS OF RESTORING THE BOWEL AFTER RESECTION OF GROWTHS JUST ABOVE THE RECTO-SIGMOIDAL JUNCTION. It often happens, after resecting a growth at the lower end of the pelvic colon, that it is not possible to deal with the ends of the bowel by any of the ordinary methods. The lower stump is too short to reach the skin, and owing to its immobiUty, and position at the back of the pelvis, it is impossible to perform anastomosis, although the upper stump of colon is quite long enough to reach it. AFTER RESECTION OF GROWTHS 313 There are two methods by which the bowel can be restored under such circumstances. If the upper stump is long and has a long mesentery (not less than 5 inches), the surgeon can free the lower stump all round from the abdomen, and, by making Sigmoid. Recto-sigiiioidal junction. Growth. fi'ig: 87. — Photograph of the parts removed by abdomino-perineal e.vcision for cancer at the recto-sigmoidal junction. The specimen includes the whole rectum and half the sigmoid flexure. It measured 14 inches in length. The patient made a good recovery, and had excellent control over the new rectum, which was formed by bringing down the stump of the sigmoid flexure and stitching it to the anus. {Author's case). an incision in the perineum, excise the entire lower portion of bowel, in fact, perform abdomino-perineal excision of the rectum, bringing the stump of the sigmoid down to the anus and fixing 314 RESTORING THE BOWEL it there. This is a formidable operation, but, if successful, it gives very good results. A photograph is appended {Fig. Sy) showing the parts removed in such a case. The patient recovered and had excellent control over the bowel. Another method of deahng with such cases, and one which is simpler and does not involve the removal of a normal rectum, is as follows : — After the growth has been resected, a long glass tube or one of the author's rubber tubes is tied into the upper stump of the pelvic colon, and the free end of this tube is then passed into the lower stump and pushed down until it can be ♦ drawn out of the anus by an assistant. The edges of the lower stump are made to invaginate, so that the peritoneal surfaces of the two portions of bowel come into contact. A few sutures are then" inserted, if possible, to fix the two portions of bowel together, and the abdominal wound is closed. The hne of junction cannot leak until the tube separates, and by that time firm union should have taken place. (See Fig. 88.) The condition produced is practically a short artificial intus- susception, the two peritoneal coats being in apposition, and the ends of the mucous coats close together, though not necessarily touching each other. Owdng to the glass tube tied into the upper portion of the bowel, no leakage can occur, and the ends of the bowel have about a week in which to become united to each other before there is any possibility of strain being thrown upon the line of union ; while the tube is stiD in position the bowels can be freely opened without any risk of leakage, and this is a very great advantage in the case of an anastomosis so near the rectum. The following is an instance in which this operation was per- formed with successful results : — Case. — I saw the patient, a man, aged 53 years, on Oct. i8th, 1907, on account of haemorrhage from the bowel. His history was that for nearly twelve months he had been passing mucus and occasionally blood, and had had attacks of pain in the abdomen. About a month previously he had a profuse haemorrhage from the bowel, and this had occurred again the day before I saw him, and had been accompanied by severe pain in the abdomen lasting for about half an hour. On examination per rectum nothing abnormal could be felt, but very high up a large resisting mass could be felt through the anterior rectal wall. Under ether, by bimanual examination, and after stretching the sphincters so as to allow of two fingers being inserted into the rectum, a gro^\i;h could be distinctly felt in AFTER RESECTION OF GROWTHS 315 the lower part of the sigmoid flexure. This diagnosis was confirmed by sigmoidoscopy. The operation was performed on Nov. 4th. The patient was anaesthetized with ether by the open method. The patient having been placed in the Trendelenburg position, an incision was made through the outer part of the rectus sheath on the left side of the abdomen and extending right down to the pubes. On opening the abdomen I found that the lower part of the growth extended down to within one and a half inches of the recto-sigmoidal junction, and that a loop of the sigmoid flexure above the growth had become adherent to, and was involved in, it. This necessitated the removal of all but a few inches of the sigmoid flexure if the growth was to be removed. The sigmoid flexure was divided above the involved 8. — (S) Sigmoid. (R) Rectum. (G) Glass tube, to the upper end of which the sigmoid is tied. (B) Piece of rubber tube to prevent glass tube from slipping up into rectum. loop, and the mesosigmoid was stripped up from the posterior pelvic wall and the vessels clamped as they were divided. This procedure was rendered necessary by the fact that some of the glands in the mesosigmoid were involved. As a result of the stripping up of the peritoneum, the great iliac vessels were laid bare. The sigmoid flexure at the recto-sigmoidal junction was now divided an inch below the growth, and the adherent loops were removed. The peritoneum was brought together by stitches over the posterior pelvic wall, and all bleeding points were ligated. At this stage, owing to the rectum not having been properly emptied previously to the operation, some soiling of the pelvic peritoneum unfortunately took place. Any of the ordinary methods of end-to-end anasto- mosis were quite impossible owing to the depth of the wound and 3x6 RESTORING THE BOWEL to the fact that there was no stump of bowel below, but merely a hole in the pelvic floor. I tied a glass Keith's tube into the upper end of the sigmoid flexure, and passed the free end of this tube, to which a piece of large-bore rubber tubing had previously been attached, down into the rectum from the abdominal cavity. An assistant then caught this with forceps introduced per anum, and drew it out of the anus. By drawing on the Keith's tube, the upper end of the sigmoid flexure was invaginated into the upper end of the rectum, thus forming a kind of intussusception. Two or three silk stitches were then put in to prevent the invagination from coming undone. A drainage-tube was then inserted and the abdominal wound was closed in separate layers. The bowels were freely opened with calomel on the third day through the tube. The tube separated and came away on the seventh day ; after this a faecal fistula formed along the track of the drainage tube, and there was some discharge for a time, but the bowels continued to act by the rectum. The patient made a good recovery without any bad symptoms, and although the faecal fistula was a troublesome complication, it soon began to close, and in the course of a couple of weeks only allowed a little flatus to escape occasionally and soon healed. The patient is quite well at the present time, two years after operation. There is no trace of a stricture, and he has normal control over the action of his bowels. Resection of the Entire Colon. — I believe the first case in which this operation was performed successfully was one in which Lienthall, an American surgeon, resected the whole colon for multiple adenomata. The operation was performed on June 15th, 1900. The patient was a woman, aged 21, whose colon from end to end was covered internally with small adeno- mata which caused dangerous and intractable hemorrhage. The operation was performed in two stages, and the patient recovered. Arbuthnot Lane was, however, the first to com- plete the resection at one operation. He has performed it a considerable number of times, and has proved that it can be done with a comparatively low mortality. The technique is as follows : — A large median incision having been made, and the abdomen opened, the ileum is divided at a point about five or six inches from the csecum. A hgature is first placed round the ileum, and the latter is then divided with a cautery. The stunip is next buried in the proximal bowel by means of a purse-string suture. Next, the adhesions and peri- toneum which bind the caecum and ascending colon to the AFTER RESECTION OF GROWTHS 317 posterior abdominal wall are divided, and the bowel is raised until the vessels supplying it are exposed. These are seized in forceps and ligatured. The transverse colon is similarly treated. The vessels are first controlled, and then the colon is freed. The descending colon, and as much as is considered advisable of the sigmoid flexure, are similarly freed. A point having been chosen in the sigmoid, which will leave a long enough stump after division to enable the anastomosis to be performed, the bowel is divided at this spot, the lower end being closed in the same way as in dealing with the ileum. The whole colon is now free and can be removed. The closed end of the ileum and the closed stump of the sigmoid are then brought together and joined by lateral anastomosis. Lastly, the edge of the mesentery of the ileum is stitched to the edge of the mesosigmoid, so as to prevent there being any gap through which bowel might prolapse and become strangulated. Mr. Lane passes a fine gut ligature through the free incised margin of the mesentery of the ileum, and then beneath the peritoneum forming the outer wall of the mesorectum. When this is tied it brings the rectum to the middle line of the pelvis and fixes it in that situation. The ■operation may also be performed in two stages, by first doing an ileo-sigmoidostomy, and later resecting the colon. 3i8 INDEX Abdomen, palpation of the Abdominal muscles, exercises for strengthening the . . Abnormalities, congenital Abscess, as complication of ulcer- ative colitis — a result of pericolitis 193, Absorption of food constituents by the colon Acute dilatation . . Adeno-carcinoma Adenomata, multiple — villous Adhesions following pericolitis — a cause of constipation — and kinking . . . . symptoms treatment Age incidence in volvulus Amoebic dysentery Aucesthetic, examination under Anastomosis, spontaneous, from cancer of colon — technique of . . . . 29 Anatomy and development Animals, variations of the colon in Antiperistalsis Anus, artificial, closure by oper ation — — operation to form Appendices epiploicas causing constriction Appendicitis a cause of kinking — causing mucous colitis Appendicostomy for chronic co litis — catheter — for constipation dilated colon haemorrhagic colitis — opening, to close — technique of . . — in tuberculosis — — ulcerative colitis Arsenic in chronic colitis Arterial circulation — thrombosis a cause of meteor ism. . Arteries, embolism of colic Artificial anus, closure by oper ation — — operation to form PAGE 43 224 58 178 14 32 249 237 237 194 95, 221 92 94 102 87 156 55 260 307 291 280 135 145 296 227 74 169 299 294 214 174 141 4 32 235 291 280 page; Artificial anus, physiological re- sults of . . . . . . 29' — — in ulcerative colitis . . 174 Asylum dysentery . . . . 156- Bacillus bulgaricus . . . . 38- — — in preparing patient for operation . . . . . . 303 — coli . . . . . . . . 38 — dysenterise . . . . . . 154 — of tubercle . . . . . . 40 Bacteria in colon, modification in preparing for operation 303 Bacteriology of the colon . . 37- — — ulcerative colitis . . 156 Bailey's modification of Witzel's colotomy . . . . . . 283 Belladonna in chronic colitis . . 141 enterospasm . . . . 153 Bismuth in X-ray diagnosis . . 51 Blood in stools, diagnostic impor- tance of . . . . . . 57 Blood-supply, interference with, a cause of meteorism . . 32 Blood-vessels . . . . . . 4 Bougies and tubes in diagnosis . . 55 Bulgarian bacillus . . . . 38- — — in preparing patient for operation . . . . . . 303 C^cosTOMY for chronic colitis . . 144 — — irrigation of colon . . 300- — technique of . . . . . . 289 — for ulcerative colitis . . 174 Caecum as an organ of digestion i — volvulus of . . . . . . 83 Cancer . . . . . . . . 249 — associated with pericolitis . . 195 — a cause of chronic mucous colitis . . . . . . 136 — intussusception . . 120 — indications for removing . . 267' — lines of extension of growth 253 — morbid anatomy . . . . 250 — palliative operations . . 273 — predisposing causes . . . . 250- — recurrence after excision . . 272 — secondary results of . . . . 260^ — spontaneous anastomosis in . . 261 — symptoms . . . . . . 255 — treatment . . . . . . 263; INDEX 319 290 33 28 127 95 4, 127 143 ■ 132 139 12S 167 237 201 154 156 155 157 165 161 172 Carbon dioxide, its origin in acute dilatation . . Catarrhal colitis causing mucous colitis Cholin in the faces Chronic constipation — — treatment — mucous or membranous colitis Closure of ftecal fistula by oper- ation CO2, its origin in acute dilatation Colectomy, physiological results of .. " .. Colica mucosa Colitis, caused by adhesions — chronic mucous or membran ous . . . . 2 operations for pathology and etiolo treatment — — — symptoms — hemorrhagic . . — polyposa — tuberculous . . — ulcerative — — bacteriology — — etiology — — pathology — — prognosis . . — — symptoms — — treatment — various types of inflamm.ation 137 Colon, length of — surface markings of . . . . 8 Colopexy, technique of . . 312 Colostomy for ulcerative colitis 174 Colotomy . . . . . . . . 280 — in cancer . . . . . . 264 — closure of . . . . . . 290 — ■ for chronic colitis . . . . 144 congenital dilatation and hypertrophy . . . . 73 ■ — inguinal, technique of . . 281 — lumbar, technique of . . 285 — opening, control over — as palliative in cancer . . 275 — Paul's method . . . . 287 — preparation of patient for . . 302 — sensation at the opening after 15 — valvular . . . . . . 283 Congenital abnormalities of the colon . . . . . . 58 — — peritoneum or mesentery 59 — causes of volvulus . . . . 78 — dilatation and hypertrophy. . 61 — — — diagnosis of . . . . 64 — — — etiology of . . . . 65 — — — morbid anatomy of — — — prognosis of . . . . 72 — treatment of . . . . 72 Constipation, adhesions a cause of .. .. ••93 AGE PAGE Constipation, atonic . . . . 220 33 — in cancer . . . . . . 258 — chronic . . . . . . 218 137 — — operative treatment . . 226 26 — — treatment . . . . 221 218 — exercises for .. .. .. 224 221 — use of X rays in diagnosis of 218 127 Contents of the colon . . . . 24 Contractions of mesosigmoid from pericolitis . . . . . . ig6 Croup, mucous . . . . . . 127 Deformities of mesosigmoid from pericolitis . . . . 196 Development of the Colon . . 9 Diagnosis by means of bougies and tubes . . . . 55 — methods of . . .. .. 41 — the sigmoidoscope in . . 44 — X raj'S in . . . . . . 51 Diarrhoea, causes of . . . . 26 — membranous or mucous . . 127 — in multiple polypi of the colon 243 — in ulcerative colitis . . . . 161 Diet in chronic colitis . . . . 141 — Von Noorden's . . . . 141 Dilatation, acute . . . . 32 — and hypertrophy, congenital 61 — post-operative, causes of . . 35 — resulting from cancer . . 261 — secondary results of.. .. 68 Distention or stercoral ulcers . . i6g Diverticula causing pericolitis .. 181 Doyen's method of anastomosis 309 Dysentery, bacillary, and ulcera- tive colitis . . . . 156 — stricture after. . . . . . 234 — tropical, and ulcerative colitis 134 Electrical treatment of adhe- sions . . . . . . 103 — — chronic constipation . . 225 Embolism of colic blood-vessels 235 End-to-end anastomosis, tech- nique of . . . . . . 307 Enteritis membranacea . . 127 Entero -colitis . . . . . . 127 Enteroliths causing chronic con- stipation . . . . . . 228 Enteroptosis causing mucous colitis . . . . . . 135 — of transverse colon . . . . 107 Enterospasm . . . . . . 150 Enterotome for closing colotomy opening . . . . . . 292 Epicolic glands . . . . . . 7 Examination of the stools . . 56 Exercises for chronic constipation 224 Excision of bowel for cancer . . 263 — physiological results of 28 Exploratory laparotomy, when indicated . . . . . . 56 320 INDEX PAGE F^CAi, calculi . . . . . . 228 — fistula, closure by operation 290 — impaction . . . . . . 228 symptoms.. .. .. 230 — — treatment . . . . 231 Faeces, acid reaction of . . . . 27 — bacteriological content of . . 37 — colour of . . . . . . 26 — examination Crf . . . . 56 — in mucous colitis . . . . 130 — normal and abnormal con- stituents in . . . . 24 Fat in the stools . . . . . . 25 Fibrolysin in treatment of adhe- sions . . . . . . 103 Fistula, faecal, closure by oper- ation . . . . . . 290 Fistulae following pericolitis . . 194 Flexner's acid bacillus in ulcera- tive colitis . . . . 156 Foetus, development of the colon in the . . . . . . 9 Follicular ulceration . . . . 166 Food constituents, absorption by the colon . . . . . . 14 — indigestible, a cause of intus- susception.. .. .. 120 — time occupied in reaching and passing colon . . . . 19 Functions of the large intestine 13 Gangrene causing intussuscep- tion . . . . . . 120 Gas-pipe colon . . . . . . 212 Glandular system . . . . 7 Glutinous diarrhoea . . . . 127 Granular colitis causing chronic mucous colitis . . . . 137 Growths in pelvic colon, restoring bowel after resection of . . 312 HEMORRHAGE as Complication of ulcerative colitis . . 178 Haemorrhagic colitis . . . . 167 Hepatic flexure, cancer of . . 269 Hernia of the colon .. .. in Hirschsprung's disease . . . . 62 History as guide to diagnosis . . 41 Hydrotherapy in chronic consti- pation . . . . . . 226 Hyperplastic tuberculosis . . 202 Hypertrophic colitis with chronic mucous colitis . . . . 137 Hypertrophy and dilatation, con- genital . . . . . . 61 Hyrax, arrangement of the cae- cum in the . . . . 2 Idiopathic dilatation . . . . 62 Iguana, function of caecum in the i Ileocsecal angle, cancer of . . 255 — artery and its branches . . 5 — valve, anatomy of . . . . 3 Ileo-colostomy as palliative in cancer Ileo-sigmoidostomy for chronic colitis — for chronic constipation — — dilated colon — methods of . . — physiological results of Indicanuria, Obermeyer's test for Inflammation causing chronic mucous colitis Inguinal colotomy Injection treatment of intussus- ception Injury to the colon in animals, sensory effect of — — effect of experimental Intestinal sand . . . . 25, Intra-abdominal pressure, to restore Intussusception . . — - etiology — experimental . . — pathology — prognosis — spontaneous elimination of — symptoms — treatment Irrigation of colon, appendicos tomy for caecostomy for fluid used in Kinking and adhesions.. Lactic acid bacilli — — ferment in preparing patient for operation . Lane's method of anastomosis . Laparotomy, exploratory, when indicated . . Lateral anastomosis, technique of — implantation of bowel Lemur, arrangement of the colon in the Lienteric diarrhoea, causes of Lumbar colotomy Lymphatics Madelung's method of anasto- mosis Malformations giving rise to volvulus . . Malignant disease causing chronic mucous colitis Massage for adhesions . . — chronic constipation . . Membranous colitis Mental condition in mucous colitis 274. 145 228- 75 311 28 57 137 281 124 15 15 131 109 114 115 115 120 126 121 122 124 294 300 297 92 38 303 309 56 309 310 26 285 5 309 78 249 136 102 223 127 130 INDEX 321 PAGE Mesentery, abnormalities of, causing volvulus . . 78 — congenital abnormalities of . . 59 — development of the . . 11 Mesocolon, operation for shorten- ing 92 — method of dealing with, in resection . . . . . . 306 Mesosigmoid, deformities and contractions following pericolitis . . . . . . 196 — operation for shortening the 311 Meteorism . . . . . . 32 — post -operative, causes of . . 35 Methods of diagnosis . . . . 41 — — restoring the bowel after resection of growths . . 312 Micro-organisms in intestinal contents . . . . . . 37 Monkeys, the cagcum in . . i Morbid physiology . . . . 28 Mucous or membranous colitis . . 127 — secretion and diarrhcea . . 26 Mucus, diagnostic importance of 56 — normal presence in colon 24, 56 Multiple polypi . . . . . . 237 Murphy's button in anastomosis 268, 307 Nerve supply . . . . . . 14 Nervous symptoms in mucous colitis . . . . . . 130 Neurin in the faeces . . . . 26 Neurosis theory of mucous colitis 132 Normal contents of the colon . . 24 Nothnagel's neurosis theory of mucous colitis . . . . 132 Obermeyer's test for indicanuria 57 Obstruction due to cancer, treat- ment by operation . . 263 — chronic, from angulation or kinking . . . . . . 96 Occlusion of colon, physiological results of . . . . . . 28 Olive oil in chronic colitis . . 140 Omentum, development of the. . 11 Operation, preparation of patient for . . . . . . . . 302 Orang-utang, the caecum in . . i Pain in the colon only indirect . . 15 Palpation of the abdomen . . 43 Paracolic glands . . . . 7 Patient, preparation of, for oper- ation . . . . . . 302 Paul's method of colotomy . . 287 — operation in cancer . . . . 265 Pelvic colon, anatomy of . . 9 — — volvulus of . . . . 83 Percussion of the abdomen . . 43 Perforating pericolitis, treatment 199 — ulcer, treatment . . . . 176 PAGE Perforation causing pericolitis.. 188 — of colic ulcer.. .. 160, 170 Pericolitis . . . . . . 179 — etiology . . . . . . 180 — diverticula causing . . . . 186 — pathological conditions arising from . . . . . . igr — symptoms . . . . . . 189 — treatment . . . . . . 197 Peristalsis, effect of colonic con- tents on . . . . . . 17 — causes of . . . . . . 19 — experimental . . . . . . 17 — rate of . . . . . . 21 Peritoneum, abnormalities of, causing volvulus . . . . 78 — congenital abnormalities of . . 59 Peritonitis, adhesions following 93. — as a cause of acute dilatation 34. — general, following pericolitis 196, 199 Petroleum in chronic colitis . . 142 — chronic constipation . . 222 Physiology . . . . . . 13 — morbid . . . . . . 28 Polypi associated with other conditions . . . . . . 246 — cancerous . . . . . . 259 — malignant tendency . . . . 242 — multiple . . . . . . 237 — — symptoms.. .. .. 243 — — treatment . . . . 246 — predisposing to cancer 250, 253 Polypus as the starting-point of intussusception .. .. 117 Post-operative meteorism, causes of 35 Preparation of patient for oper- ation . . . . . . 302 Re-absorption of water by the colon . . . . . . 13 Rectal bougies and tubes in diag- nosis 55 Rectum, the normally empty state of 23 Resection and anastomosis of colon . . . . . . 302 — — multiple polypi . . . . 248 — — physiological results of . . 28 — of dilated colon . . . . 74 — entire colon, technique . . 316 — growths, restoring the bowel after . . . . . . 312 Reversal of colon, experiments in 23 Rupture of colon . . . . 276 Saline infusion in operations Sand, intestinal . . Sarcoma . . Segmentation Sensory nerves . . 305 25 262 22 15 322 INDEX Shiga's bacillus dysenteriae in ulcerative colitis . . 156 Shock in operation, prevention of 305 Sigmoid flexure, anatomy of . . 9 cancer of . . . . 255, 270 — — on right side . . . . 60 Sigmoidoscopy, technique of . . 44 Simple stricture of the colon . . 233 — tumours . . . . . . 237 Spasmodic stricture of the colon 150 Splenic flexure, cancer of . . 269 Stercoliths in diverticula causing pericolitis . . . . . . 185 StercoUtis . . . . - . 228 Stercoral calculi . . . . . . 228 — ulcers . . . . . . . . 169 Stools, examination of . . . . 56 — in mucous colitis . . . . 130 Strauss's sigmoidoscope.. .. 44 Stricture of the colon, non- -^ malignant .. .. 233 — following pericolitis . . . . 194 — polypi associated with . . 246 Symptoms, method of inquiry into . . . . . . 41 Syphilis 188 Thrombosis causing meteorism 32 — or embolism of blood-vessels 235 Toxins in obstructed bowel . . 26 Transverse colon, cancer of 255, 269 enteroptosis of . . . . 107 Traumatism . . . . . . 276 — a cause of pericolitis .. .. 188 Tropical dysentery and ulcerative colitis . . . . . . 154 Tubercle bacillus . . . . 40 Tuberculosis . . . . . . 201 — • morbid anatomy . . . . 205 — hyperplastic . . . . . . 202 — — polypi associated with . . 246 — symptoms . . . . . . 209 — treatment . . . . . . 214 Tuberculous ulceration . . . . 172 Tumour formation from peri- colitis . . . . igr, 199 — — — tuberculosis Tumours, simple . . 204, 205 • • 237 PAGE Tuttle's method of colotomy . . 283 Typhoid ulceration . . . . 177 Ulcer, simple perforating . . 170 Ulceration causing pericolitis . . 188 — tuberculous . . . . . . 201 Ulcerative colitis.. .. .. 154 operative treatment of . . 173 — — perforation in . . . . 160 — — polypi associated with . . 246 Ulcers of colon, natural healing of 164 — distention or stercoral . . 169 Urine, examination of .. .. 57 Vaccine treatment of ulcerative colitis Value of the colon Valve, ileocsecal . . Vascular system . . Veins, embolisms of colic Venous thrombosis a cause of meteorism . . Vesico-colic fistula following peri colitis Vibration and massage iu chronic constipation Villous adenomata Visceroptosis Volvulus, acute, symptoms of — — treatment of — of cffical angle . . — chronic, symptoms of ■ — — treatment of — • compound — etiology of — pathology of . . — prevention of recurrence of Von Noorden's diet in chronic colitis . . . . . . 141 Water, re-absorption by the colon . . . . . . 13 Witzel's operation for colotomy 283 Wounds of colon . . . . 276 X RAYS in diagnosis . . . . 51 • — of chronic constipation 218 observation of peristalsis 19 172 14 3 4 235 32 194 224 237 107 76 87 83 71 91 87 78 JOHN WRIGHT AND SONS LTD., PRINTERS, BRISTOL RGiBSO Lo ckh art-Mummery Diseases of the colon* L81 RC8bO