I. Murray
1927 BMJ (Clinical Research Edition)  
THE THYROID GLAND IN THE FOETUS AND NEWLY BORN. [eTiR,me 5 to radical operationi, but with regard to glaindular enlargement it mutst be rem-embered thliat this is niot niecessarily of a secondary maligiant character, but may be of an inflamiimatory niature only, due to associated sepsis. Local hNity, moreover, rarely prevents radical measures, since ly free division of the peritonieuiii along the outer border of the colon, maniy growths which at first sight appear too fi*ed miiav be rendered
more » ... iiav be rendered sufficiently mobile for excision. If a radical operation be definiitely contraindicated then a dsl sort-circuit " (that is, lateral anastomosis) should be Performed, provided there is *a sufficient length of colon below the growth to permit of approximation to the distended bowel above w-ithout undue tensioni. Only.when a short-circuit is quite impossible must we, as a last resort anid to preveint futu-tre intestinal obstruction, fall baclk on colostomy proximal to the growth. Many cases, however, are already associated with intestinal obstructioni whieni first seen, and it is imnperative that this be relieved before any radical extirpation with restoration of the continuity of the bowel be attempted, since it is th-e uiiversal experienice of surgeons that resection of the colon in. tlh p-resence of obstruLctioni is a very unsafe plocedure-the conlgested aind oedenmatous wall of the bowel failing to hold the sutures properly, so that leakage at the suture linie is very probable. In such cases the best course, I believe, is to perform caecostomiiy under nitrous oxide or local aniaestlhesia; only when, by this means, complete relief of the obstruction has beeni attained must r-ecourse be lhad to exploratory laparotomy with a view to r.adical removal of thle growtth and restoration of the continiuity of the bowel. If after this has beeni accomplished tlhe caecostomiy does iiot close spontanieously, a slight plastic operation. will suffice for its obliterationi. CANCER OF THE RECTUTM. It is ani extremiiely unifoltuinate fact that at the present time fully 75 pler cenit. of the cases cominlg to our hospitals with cancer of the rectum have already reached a stage mluch too advanced for ainyv hope of radical operation. This is surprising whiien it is remembered that such growths are readily available to rectal palpationi, an-d it is largely tlhe nieglect to makie a digital examiniation of the rectuim ellienever patienlts come complaining(,of rectal symptoms that is respoonsible for this lamentable state of affairs. Even when blood has been passed per anum it is not ulnconmmonly too readily assumed that it is due to the common-est cauise-piles-without a digital examination. Theo early sym1iptomiis of rectal cancer are often indefiniite, and aro essentially those already described for growth of tlhe colon. A platieiit whlose bowels lhave previously acted regularly; oii goilng to morninlg stool and thilinii-ig to have a normal motion, finds i.-stead that lhe passes mostly bloodstained niucuis and flatus, anid that lie has. to Irepeat his visit very shortly, possibly for several timiies, before he obtains relief. This " spurious-di arrhoea " is really indicative of constipation. Severe bleeding from the rectum is urcommon except in an advanced stage, but occasionally it mav be an early symptom, and theni, fortuniately, alarms the patient and( leads him to seek advice in an early and operable stage. Paini is often coumpletely absent in the. earlv stages; if presemit it miiay be felt in tlhe rectum, in the sacruim, or over tlhe lower abdomen. An alterationl in the shape of the faeces, clhiefly in the direction of flattei)ing, is soifietimes nioticed early, especially in the stenosinog type of gr-owth and wheni situated near to the ainus; with a high growth the faeces miiay be remoulded in the rectum after passing tllrouglh the stricture and tllus appear of niormal slhape. Diagnosi's and Treafnmeaf. Suispicion of rectal trouble having been aroused, a digital examination' should be made forthwith, anid should it prove nlegative a sigfmoidoscopic examiniation should follow, since thle commonest site of growth is the recto-sigmoid junietion, anld this may n.ot be reached bythe examlininlg finger. Bimanlual examinlationl with the forefinlger of onle hanld inl the rectum and the other hanld flat on thle lowXer abdomen sometimes enables an otherwise impealpable grow-th to h)e discovered. BY digital examination is determinled, nlot only the presenice of a growth in the rectumlii, but also the extent to which it has already involved tlho adjacent strluctures-prostate, bladder, vagina, uterus, anid sacrumli. If not fixed to any of tlhese, and if no enlargement of the liver can te felt (ol of the iniguinal glands in canicer's involvinig thlo anal canal), theln the question of a radical operation mlust be considered. The possibility of tllis caninot be finallv determined until, as the first operative step, the abdomen has been opened and the presence of mnetastasis in tlho liver or peritoneum, or the too Qextenisiv-C involvement ')f ly3mphatic glands, definlitelyexcluded. It has, unfortuniately, been mv experience oni mnor-e tlhan one occasion to find tihat with a comparatively smiiall anid freely mobile rectal growth-and presumably, thlerefore, an early onea seconidary deposit in the ii-erhas been disclosed on openinig the abdomen, and the conitemiiplated radical oper'ation thereby prevented. We nleed lnot to-day enter ilnto themuch discussed question of the relative merits of tlle two chief radical operative proceduri-es at p-resent in vogue: (1) the abdominio-perilneal operatioi lperfected by Miles, and (2) perineal excisioni followinig a preliminiary colostom-y; they both entail a permanienit iliac aiiuis as part of tlhe price the patienlt is called ulpon to l)ay for anly hope of cure of a rectal canecr. Possibly, in thofuture, with cases presenting themiselve3 at all earlier stage and with a better selection of cases, it may be feasible to remove the rectum with preservation of tlhe sphmincters and restoration of the continuity of tlle bow-el, butt at present such is lnot to be recommended. If a radical operation be deemiied impracticable, either because of the local extenit anid fixity of thei primla.ry growtlh or because of the presence of metastases, theni tlhe question of a palliative colostomly has to be conside'red. This should certainly be performed whlerever there is any evidence of actulal or of shortly tlreatenled ol)struction, ancd considerable relief mnay be cxpecz(ted therefrom. In the ulcerative types of growth obstruce-tion is not a marke(d feature, anid the patient's chief distress is occasioned by the profuse discharge of blood and muco-pus from tlhe growth, niecessitatingtlhe passag,e of very frequent stools; although by diverting tlhe faeces fromn the growth colostomy may be reasonably expected to, dimiinlislh the amount, of this diselarge, yet suifficienit may remiiaini to cauise patienits to express disappointmenit at the smlatli miieasure of relief afforded them by the operation, anid this should be fully explainled to them before their conlsenit to colostomy is obtailned. REFERENCES. 1
doi:10.1136/bmj.1.3443.5 fatcat:bncxncykmfftraz6fexsx5xypq