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Philadelphia: W. B Obsir 1909. icllon (Obslipalioii). of ichthyol, hydrastis, krameria, and free sign up bonus no deposit required casino soda, potas- sium permanganate, or boric acid, to reduce the free online casino games no deposit bonuses in- flammation and heal the ulcers. When enterospasm is of latest casino bonuses free slots frequent online casino games with free sign up bonus occurrence, it can be effectively controlled by the administration of small doses of belladonna alone or in combination with opium. In cases of obstipation induced by hypertrophy of O'Beirne's sphincter to such an ex- tent that the bowel is considerably occluded, its divulsion is indicated. It can be easily and quickly dilated by introducing a large proctoscope up to the obstructed point and then passing a Wales bougie of proper size through it. Divulsion can also be satisfactorily accomplished by tamponing with a rubber bag distended with air or free no deposit casino bonus codes usa only water left in situ as long as may be required. The sphincter should be intelligently dilated daily or two or three times weekly, according to the exi- gencies of the old casino games for sale case, but careless stretching with bou- gies and mechanical dilators is to be avoided owing to the danger casino games list wiki of rupturing the gut and causing peritonitis. When the treatment outlined fails, surgical in- tervention is imperative, and the obstruction should be relieved by colostomy, resection of the sphincter, or by making an anastomosis between the sigmoid above and the rectum below. 2. Hypertrophied rectal (Houston's) ' valves: (Fig. I.) The rectal valves may become hypertro- phied as the result of chronic colitis, ulceration, and other affections of the lower bowel, and when they are rigid may project into the lumen of the gut and prevent the faeces from reaching the anal outlet ; un- der such circumstances, lumps of ffecal matter can often be seen or felt resting on the upper or concave surface of the valves. Some writers state that the obstinate constipation occasionally induced in this way can be corrected by rectal bougie or massage free welcome bonus no deposit required casino of the valves. I have tried this plan of treatment many times, but have never known it to relieve constipation when used alone. When the valves are markedly thickened and rigid, nothing short of division will effect a cure. Martin first suggested valvotomy and devised a method of performing the operation wherein he ex- posed the valves by means of the proctoscope, di- vided them with a bistoury, and closed tlie wound with catgut, using a long handled needle, or per- mitted the cut to heal by granulation. The Martin operation is unsatisfactory because it takes consid- erable time, is accompanied by profuse bleeding difficult to control, there is danger of infection, the patient complains bitterly of gas pains induced by blocking of the rectum with tampons, it has been Copyright, 191 1, by A. R. Elliott PublishinR atlantis gold casino free spins bonus codes Company. GANT: RECTAL CONSTIPATION AND OBSTIPATION. [New York EDiCAi, Journal. followed by peritonitis, and confines the patient V> his bed for several days. In order to overcome the disadvantages of Mar- tin's operation, Pennington devised a clip, which divides the valves by pressure necrosis. This in- strument has not given entire satisfaction in the writer's hands, because it does not sever the valves deeply enough, and further, because it is difficult or impossible to remove and replace once it has been improperly adjusted. Shortly after the advent of the Pennington clip I devised a clamp with which the valves can be satis- download free casino games for my blackberry factorily divided, and also applicator forceps, by means of which it can be easily and quickly applied. (Fig- 2.) , , . . , The technique of the writer s valvotomy is as fol- lows: A clamp is placed in the applicator and its jaws opened by locking the handles of the instru- ment and the forceps laid aside. The patient is then placed in the knee chest online casino no deposit bonus codes march 2012 posture, the rectum is in- flated, and the valve exposed by means of an oper- ating proctoscope and reflected light. The instru- ment is then picked up and the clamp is pushed well down over the centre of the valve and released by unlocking the handles of the forceps applicator. (Fig- 3-) The entire procedure requires but a moment and rarely causes pain or discomfort. In order to pre- vent pain from the air which has entered the bowel free bonus no deposit casino usa welcome during the inflation, the patient is placed upon the left side and told to strain, while the proctoscope is being removed in order to permit it to escape. I have performed more than one hundred valvotomics in this way, and the results have been very satisfac- tory. The principal advantages of the clamp opera- tion are ; It can be performed in the office, requires but a moment, causes but little if any pain or bleed- ing, there is no danger of infection, it does not in- terfere with the occupation of the patient, and efifec- tively divides the valve, which drops downward, and no longer interferes with the movement. Lynch has devised a cautery apparatus for divid- ing the valves but I have had no personal experi- ence with it, but have treated one case of rectal car- cinoma at the point where a valve had been divided in free casino bonus slots for fun this way, and the patient thought the growth was referable to the valvotomy performed some months previously. Hirschmann has suggested division of the valves with a rubber ligature, and has invented a carrier for the purpose. I have tried this melhod on several occasions, but have discarded it for the reason that it is cumbersome, causes considerable pain when the ligature carrier latest casino bonuses free games is pushed through the valve, and has no advantage over the clamp which free spin casino bonus codes is voided in the faeces when it sloughs oQ. In some instances valvotomy is followed by an immediate cure, but in the majority of cases I have found it advisable to regulate the diet or institute a postoperative hooters casino las vegas free slot play course of massage, electric or vibra- tory treatment to stimulate and strengthen the rec- turn and colon, which are often atonic. Increased frequency of the evacuations imme- diately following this operation may be partly at- tributable to stretching of the sphincter by the large proctoscope and ])artly to the ulcerated wound left, which serves to excite more frequent and efifective peristalsis. I have never known a stricture to fol- low division of the valve free casino bonuses uk in this free casino bonuses codes way. Valvotomy is a very useful procedure, but the necessity for latest free casino bonuses it does not arise nearly so frequently as the writings of some authorities would indicate.

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