Robert Turell

PROCTOLOGIC ASPECTS OF CONSTIPATION AND DIARRHEA

Diarrhea from any cause, even of short duration, may produce proctologic complications. Significant complications are most usually observed, however, in diarrheas of long standing, as in chronic ulcerative colitis. Cancer of the colon and rectum is the most important, while infections of the anal structures are the most frequent comp1ications.l I t should be recalled that the anal ducts which usually empty into the anal crypts of Morgagni lead to racemose multiglandular structures situated in the perianal tissues, even piercing the sphincteric musculature. The columnar epithelium lining the anal ducts is cuboidal in branches and, under suitable conditions, may become a natural incubator for bacteria. Infection of the anal crypts, anal ducts, and anal glands occurs frequently as a result of the mechanical deposition of infected, usually liquid, fecal material within the anal crypts which may lead to the eventual development of perianal and perirectal suppurations eventuating in anal fistulas. Conservatism is practiced whenever possible. Operations for subacute or chronic anorectal lesions accompanying diarrhea, such as hemorrhoids or anorectal fistulas, should be delayed until the underlying disease of the colon is either controlled or eradicated, with the possible exception of chronic anal fissures (ulcers) which, because of the excruciating pain they frequently produce, may demand surgical intervention. On the other hand, acute situations such as suppurations should be accorded prompt drainage by incision and wide unroofing of the abscessed cavity, both to prevent further spread of the suppurative process and to relieve the accompanying pain. Acute anal fissures or exacerbation of chronic fissures that do not respond to conservative measures, such as hot hip baths and the topical application of cocaine or its derivatives (which, incidentally, are strong cutaneous sensitizers), may necessitate immediate surgical intervention. Low or even high anal fistulas are best extirpated a t a propitious time. The irreversible pathologic changes of the colon, such as shortening of the gut, stricturization, perforation, pseudopolyposis, and massive hemorrhage encountered in chronic ulcerative colitis are mentioned but will not be discussed. A solitary adenomatous polyp, unlike a pseudopolyp, observed in association with ulcerative colitis or amebic dysentery, that is situated within the reach of the endoscope, is managed in the same manner as is such an adenoma occurring in normal colons. However, frequent posttherapy endoscopic supervision is more urgent in these patients for the earliest detection of recurrent or new adenomas which have a great propensity to undergo malignant degeneration. It should be stressed that, while cancer in ulcerative colitis frequently begins in an adenoma,2 it certainly develops very often in the absence of any visible

Tattooing (puncturation) with mercury sulfide for the treatment of intractable pruritus caused by leucoplakia-kraurosis vulvae

Abstract A patient with intractable pruritus caused by leucoplakia-kraurosis was successfully treated with the intracutaneous deposit of mercury sulfide by tattoo, after a partial vulvectomy and four subsequent surgical procedures for the removal of involved or recurrent areas of skin had failed to control the distressing pruritus.

A Method of Proctology

This is an interesting and valuable single-authored book. It presents a vivid example of the contrast between the values of solo vs multiple-authored books. It is recommended for those who would appreciate the limitations inherent in such a treatise. Here, philosophy and personal preference for and against various methods and procedures, rather than controlled studies by qualified authors, play an enormous role. Since pros and cons require profound discussion, MacLeods reader has to be directed to other, more elaborate sources of information. This applies not only to the selection of controversial, but even to accepted, methods and procedures, especially where several different ways or methods exist to manage the same problem. Selectivity is of enormous importance. This book does not provide enough basic or fundamental background material for the teaching of medical students or for the training of residents. Nor is it intended for the sophisticated general and/or intestinal surgeon.

The Management of Bowel Evacuation in Surgical Patients

Introduction Many patients who undergo anorectal operations require an agent that will promote the smooth passage of stool of normal or near-normal bulk at the first postoperative bowel action. Dioctyl sodium sulfosuccinate U. S. P. (Colace) has proved to be a safe agent for this purpose, after surgical procedures for pilonidal disease, and in colostomized patients after abdominoperineal resection of the rectum. This compound is also receiving a trial after resection and anastomosis of the colon and following electrocoagulation of adenomas. In my practice, following the performance of anorectal operations, use of dioctyl sodium sulfosuccinate is now standard procedure in place of conventional liquid petrolatum, which has been almost completely superseded. A stimulant-laxative (pericolace) is required in addition to dioctyl sodium sulfosuccinate for some patients, mostly elderly persons, as well as for the preponderance of those patients who are habituated to cathartics. Occasionally a flushing saline enema with or without