REPRINTED F'PtOIVl 
UNIVERSITY 
Medical Magazine. 
eoifto UNDER THE AUSPICES OP THE ALUMNI ANO FACULTY OF MCOIClNl 
EOlTOr.XAL ST AFP 
SH-.V 
SSEar 
Cdilofial Committaa: 
(jp: 
S-S-ii"—•" ::= 
mc& «aoo a. viar rw tVrT.y-Ti. 
JULY, 189Q 
CASE OF CARCINOMA OF DESCENDING COLON; 
EXCISION AND ANASTOMOSIS; RECOVERY. 
BY JOHN H. MUSSER, M.D., 
Assistant Professor of Clinical Medicine, University of Pennsylvania, 
ANI) 
THOMAS S. K. MORTON, M.D., 
Professor of Surgery in the Philadelphia Polyclinic. J. H. M., nine months after operation. CASE OF CARCINOMA OF DESCENDING COLON; EX- 
CISION AND ANASTOMOSIS; RECOVERY. 
By John H. Musser, M.D., 
Assistant Professor of Clinical Medicine, University of Pennsylvania, 
AND 
Thomas S. K. Morton, M.D., 
Professor of Surgery in the Philadelphia Polyclinic. 
J. H. M., aged 52 years, a grain-broker, native and resident of 
Western Pennsylvania, a patient of Dr. William L. Lowrie, of Tyrone, 
Pa., was seen in consultation by Dr. Musser in August, 1895, at his 
home. 
His father died of apoplexy when 57 years of age; mother is 
living, aged 79 years. Two’ brothers are living and well. A sister 
died of hip-disease in her thirtieth year. He has five healthy children, 
and lost one, aged 10 years, of epilepsy. 
He had had no previous illness of note, excepting attacks of 
rheumatism in 1885 and 1889, and for twenty years has been subject 
to frequent attacks of “ nervousness.” These seizures were marked 
by curious feelings in the splenic region and back, and accompanied 
by vertigo and coldness of the extremities. They have gradually 
grown more marked. During the latter half of this long period he 
has much of the time observed a condition of “uneasiness” in the 
region indicated; also for several years has felt something like a 
hitch or slight obstruction to action of the bowel referred to that 
point. A “ knotting” of flatus in that region has also been vaguely 
felt for a long time. Twenty years ago he had a severe attack of pain 
in the same portion of the abdomen. He was then freely blistered 
just below the ribs. This pain was dull and aching in character, and 
has recurred more or less severely at irregular intervals ever since. 
During the past two years it has been more severe and frequent. 
For nearly fifteen years the bowel movements have always been of 
small diameter, and for eight months never larger in diameter than 
one-third to one-half inch. For a year he had a constant feeling of John H. Musser and Thomas S. K. Morton. 
2 
obstruction upon the left side, accompanied with a sense of fulness 
upon the right. Five years since he first noted blood in the move- 
ments. It continued to be present with each stool in small amount 
for three weeks. Again, eight months before coming under observa- 
tion, he began passing clotted blood in considerable quantities. It 
had appeared especially after the bowels had been inactive, but dis- 
appeared when free catharsis was induced. He has always required 
medicine to produce a satisfactory movement. Twenty pounds of 
weight have been lost in the preceding eight months. Appetite has 
been constantly good. Great loss of strength, palpitation, breathless- 
ness upon exertion, and other symptoms of anemia have been present 
for some months. Vomiting frequently accompanies an evacuation 
of the bowels. Defecation has latterly been preceded by much pain 
and colic in the left hypochondrium. Mucus and foul odor have 
appeared with the stools within a few weeks. 
The striking objective signs at the time of the consultation were 
pallor, undoubted anemia, emaciation, and loss of strength, and a 
curious appearance of premature old age. The physical examination 
of the heart, lungs, and urine was negative. The abdomen was 
moderately distended; tympanitic except in the course of the colon. 
By ordinary methods of examination nothing unusual was found. 
The rectum contained some feces. The fecal matter discharged in 
the morning was small in amount, made up of many small pieces, 
some tinged with blood and mucus, and free mucus and blood followed 
the fecal evacuation. The colon appeared to contain feces, and hence 
high enemata were given till the bowel was empty and nothing but 
water returned. After emptying the colon of a large accumulation 
of feces, the patient was turned on the left side. In this position 
about the seat of pain, and in the course of the descending colon, an 
obscure induration was detected. The mass seemed to be half the 
size of the fist. It seemed to recede on deep palpation. After the 
high enemata were administered, the auscultatory phenomena seemed 
to indicate that the fluid was passing through a constricted orifice 
into the dilated colon above. There was more marked tympany in 
the course of the colon, replacing the dulness above noted. The 
stomach was evacuated of its contents, and its size determined by the 
usual methods of physical examination. It was decided to be free 
from disease. 
There were frequent movements of the bowels, the discharges 
being small in amount and containing some blood. Pain was the 
chief subjective symptom. This was situated in the left hypochon- 
dria, extending towards the sigmoid flexure. It was increased by 
pressure, and apparently aggravated by movement and position, a Carcinoma of Descending Colon. 
3 
peculiar position having to be assumed with sitting up in order to 
relieve the affected side. 
Diagnosis of cancer of the descending portion of the colon was 
made. This diagnosis was based upon the age of the patient; the 
exclusion of organic disease in all the other organs and structures of 
the body; the occurrence of emaciation and anemia, the cause of 
which could not otherwise be explained ; the subjective symptoms; 
the occurrence of blood in the stools; the character of the stools 
otherwise; and the physical signs of an obscure tumor in the region 
above indicated. 
The patient was advised to come to Philadelphia for surgical 
advice and treatment. He accordingly came to the city on August 
21, and was placed in charge of Dr. Morton, who, having confirmed 
the diagnosis, urged abdominal section and, if possible, excision of 
the growth. 
On August 22, under ether narcosis, an incision three inches in 
length was made through the left linea semilunaris. Through this 
opening a mass could be felt intimately connected with the colon, 
beneath the ribs, and affecting that portion of the gut immediately 
below the splenic flexure. The incision was then enlarged one inch 
upward and the whole mass easily delivered outside the wound. It 
proved to be a neoplasm involving the entire circumference of the 
colon just below the splenic flexure and about the size of an orange. 
No adhesions were present and but a single mesenteric gland was 
enlarged. The latter was located close to the tumor. The wound 
and abdominal cavity were then effectually walled off by gauze pads 
isolating the mesentery, bowel, and tumor. The colon was clamped 
in two places above and two places below the growth, but very wide 
of all infiltration, after feculent material had been well milked from 
those portions of gut between each pair of clamps. While a stream 
of salt solution was permitted to flow over the parts, the bowel was 
divided above and below between the clamps. Then the mesentery was 
divided cautiously from above downward and each vessel taken up with 
a hemostatic forceps either before it was cut or immediately after. The 
tumor, with one and a half inches of uninvolved gut above and below 
it, was thus removed without especial difficulty. The mesenteric 
vessels in the grasp of the hemostats were next ligated individually 
and the previously noted mesenteric gland dissected out. All the 
parts having been again thoroughly washed with salt solution, one- 
half of an inch-and-a quarter Murphy button was slipped into each 
end of the open bowel. The lower bowel end gave no trouble in 
adjusting the button and drawing over the intestinal walls by means 
of the purse-string, but the upper end was found thin and much 4 
John H. Musser and Thomas S. K. Morton. 
dilated or “ballooned,” and quite attenuated. With a little manoeu- 
vring, however, this difficulty was overcome and the purse-string suture 
drawn tight about the shank of the half-button, which was then 
pushed together. The considerable amount of tissue upon the upper 
portion of button interfered with firm and secure closure unless con- 
siderable force were employed. Hence thick pads of gauze were 
placed between the fingers and bowel holding the button before 
the halves were squeezed together,—thus so distributing the force as 
to spare great pressure upon any particular portions of the included 
bowel. It was considered best to run a continuous silk stitch about 
the anastomosis, bringing together serous surfaces over the junction 
line of the button. After another wash, the anastomosed bowel was 
permitted to drop back into the abdomen. The omentum was drawn 
down about most of the involved region, and, because of the great 
attenuation of the upper portion of the divided bowel, a small wick 
of acetanilid gauze was carried through the wound and its end left in 
contact with the gut just above the anastomosis. This was done to 
facilitate drainage if the thinned bowel wall should ulcerate or 
become gangrenous. The parietal wound was closed with silkworm- 
gut sutures, leaving a small space in the centre for exit of the gauze 
wicking. 
The patient bore the operation well and exceedingly little blood 
was lost. He progressed well until the second day, when a rise of 
temperature to ioi° F. demanded inspection of the wound. A little 
serum was found to be escaping along the drain. It was removed 
and about a drachm of turbid fluid escaped. A small amount of foul 
serum continued to escape for two days, and was then followed by 
occasional bubbles of flatus and a little feculent material. Temper- 
ature fluctuated from ioo° to ioi° F. for two or three days and, coin- 
cident with diminution of fecal discharge from the wound, then fell 
to normal. Very little pain was complained of at any time. Several 
movements of fluid feces—evidently having passed through the but- 
ton opening—occurred during the first four days. Liquid food was 
freely taken after the first twenty-four hours. Gas constantly escaped 
from the anus after the first day. On the tenth day the patient com- 
plained of a full feeling in the rectum and, upon1 inserting a finger, 
the button was discovered and withdrawn. Its opening was partially 
occluded by a putty-like mass of fecal material. The small fistula 
leading out of the abdominal wound now rapidly closed and gave no 
further trouble. It had evidently been caused by a small perforation 
of the thinned intestine above the button. The passage of the but- 
ton was soon followed by a very large formed bowel movement, which 
was repeated, by the aid of enemata, every day. In ten days he Carcinoma of Descending Colon. 
5 
was placed upon full diet and afterwards progressed in strength 
and increase of weight in a most gratifying manner. In three weeks 
from the time of operation the bowels were moving naturally and the 
calibre of the stools was at least an inch and a quarter. 
Five weeks after operation he was able to take a long railway 
journey to his home. Since then he has, from time to time, written 
most enthusiastic letters stating that he is as well as ever, is attending 
to a large business, is travelling all over his portion of the country, 
that his old nervous feelings and anemia have departed, that the 
bowels are moving without effort like clock-work, and that in calibre 
the stools continue to be very large. He has gained much in strength 
and has gradually mounted in weight until at the present time (May, 
1896), more than nine months since the operation, he registers 170 
pounds, or twenty-five more than when he came under our care, and 
considerably more than he had ever previously attained. 
The growth removed proved, upon examination by Dr. Thomas 
S. Kirkbride, Jr., to be large-celled carcinoma, involving the entire 
circumference of the bowel. The specimen measured in length six 
inches, of which one and a half inches of intestine, on either side of 
the tumor, was free of involvement in the cancer.