Excision of the Rectum 
FOR 
MALIGNANT DISEASE. 
By N. SENN, M.D, of Milwaukee. 
REPRINTED FROM THE INTERNATIONAL JOURNAL OF 
MEDICINE AND SURGERY. 
§Uim Dwfe: 
WM. S. FOWLER, PRINTER, 37 DEY STREET. 
1881. Ixeigus of Rectum for IfaligaM |i?eag 
By N. SENN, M. D., of Milwaukee. 
Cask I.—Mrs. W. H., mt. 6(\ German, widow, mother 
of several children, was admitted into the Milwaukee Hos- 
pital, May 26, 1880. Her family history was good. For 
many years she had been suffering from constipation and 
haemorrhoids, and for the last nine months defecation had 
been very painful, the passages being frequently covered 
with mucus and stained with blood. She had also suffered 
severely from occasional sharp, darting pains in the lower 
part of the rectum and a dull aching pain in the sacral re- 
gion. The constipation frequently alternated with diarrhoea, 
especially after taking laxative medicines, which always had 
a tendency to increase the tenesmus and pain in the back. 
The patient was considerably emaciated and anaemic, and 
on the countenance was depicted the familiar anxious ex- 
pression indicative of long-continued and severe suffering. 
On digital examination an indurated, nodular tumor, of 
elliptical shape, was detected, commencing immediately 
above the sphincters, its upper, well-defined margin being 
barely within reach of the index finger. Its centre occu- 
pied the posterior wall of the rectum, the greatest measure- 
ment of the tumor corresponding to the transverse diameter 
of the intestine and involving about two-thirds of its cir- 
cumference. The margins of the tumor were well defined 
and no indications of adhesions were present, the rectum 
being freely movable in all directions. 
At the centre of the tumor an ulceration was found of 
the size of a quarter of a dollar. Microscopical examina- 
tion of the structure of the growth revealed the presence 
of epithelial cancer-cells. Excision of the rectum having- 
been decided upon, the patient was prejjared for the opera- 
tion by first thoroughly emptying the bowels by means of 
laxatives and enemata, after which it was well disinfected by the frequent use of injections of salicylated water; the 
external parts were then thoroughly cleansed, shaved, and 
carbolized. The patient having been anaesthetized, and the 
bladder evacuated, she was placed in the exaggerated lith- 
otomy position. The operation was commenced by making 
the posterior rectal incision (introducing the left index- 
finger into the rectum as a guide), entering the point of a 
long curved bistoury above the sphincters and carrying if 
downward and backward and emerging in front of the 
coccyx; all the intervening structures were cut with one 
sweep of the knife. The hemorrhage, which was quite pro- 
fuse, was arrested by applying a number of cat-gut liga- 
tures. After making this incision it was found that the 
rectum prolapsed very easily, greatly facilitating the access 
to the diseased mass. The anus was now partly circum- 
scribed by an incision in the shape of a horse-shoe, the 
open extremity being directed forwards, and cutting through 
the loose cellular tissue behind .and on the sides of the in- 
testines ; the latter were easily separated with the index- 
finger as far as the upper margin of the neoplasm, as was 
ascertained by introducing the left linger into the rectum 
and the right into the wound. 
With blunt-pointed scissors the lateral incisions were 
now made a few lines from the margins of the neoplasm, 
and carried from the anus to the upper margin of the 
growth, thus incising the rectum longitudinally on either 
side of the recto-vaginal wall. The mass was then grasped 
with a vulsellum forceps and drawn downwards so that the 
healthy portion of the intestine corresponded to the exter- 
nal wound. Silk threads were passed through the healthy 
intestinal wall above the morbid mass and held by an assis- 
tant, so as to retain the bowel in place after excision of the 
growth, until it could be united by suture to the external 
wound. The transverse incision was made with the scis- 
sors, and all hemorrhage arrested by the application of 
several cat-gut ligatures and irrigation with cold salicylated 
water. A large drainage tube, reaching from the upper 
limits of the pelvic wound to the exterior was placed along 
the posterior median incision, and the intestine united to 
the skin by numerous antiseptic silk ligatures. The pos- 
terior rectal incision was united by means of a number of 
deep silver wires and a few superficial silk sutures, only a 
small opening being left posteriorly for the drainage tube. 3 
After another thorough irrigation of the rectum and the 
wound, a compress of antiseptic gauze was placed over the 
wound and retained with a T bandage. Although the hem- 
orrhage was very profuse, the prompt ligation of all bleed- 
ing vessels at every step of the operation, and the diligent 
use of the haemostatic forceps, succeeded in preventing seri- 
ous loss of blood ; and although the patient became very 
feeble from the moderate loss of blood and prolonged anaes- 
thesia (the operation having lasted 1A hours), she rallied 
promptly on the application of external heat and the use 
of alcoholic stimulants. Opium was prescribed to control 
the pain and arrest peristaltic action. The compress was 
removed every four hours and injections were made through 
the drainage tube. 
Without following the history of the case from day to day, 
T may state that the temperature at no time exceeded 100 
degrees. All of the intestinal sutures cut through at the 
end of the third day, the posterior median incision also 
failing to unite and the sutures were consequently removed 
to facilitate drainage; the parts were then left in the same 
condition as immediately after the excision, the resected 
extremity of the bowel having receded fully four inches. 
A moderate amount of healthy suppuration took place; 
granulations began to till the immense cavity, and during 
the process of cicatrization the rectum was drawn nearer to 
the external wound, so that after six weeks only a small 
granulating surface remained at a point previously occupied 
by the sphincter muscles. The patient was now discharged 
from the hospital, and I learned subsequently that this 
lesion healed in a short time and that she remains well up 
to the present, seven months after the operation. She has 
good control over the bowel, suffering no inconvenience ex- 
cept when the bowels become, loose, when it is necessary to 
attend promptly to the “call of nature.” 
Remarks.—The disease in this case affected the posterior 
wall of the intestine, the favorite location of rectal cancer. 
The patient had been suffering for many years from haemor- 
rhoids, an affection which, in many cases, appears to be 
antecedent to rectal cancer, and may possibly hold an aetio- 
logical relation to the latter. In regard to this point, 
Billroth says that haemorrhoidal dilatation was noted in a 
number of his cases, but that it was not a constant factor. 
All present were impressed with the advantages accruing 4 
from the posterior rectal incision. It exposed the parts 
fully during the operation, and subsequently afforded com- 
plete drainage. The hemorrhage, although profuse and 
troublesome, was controlled by using the haemostatic for- 
ceps, and ligating the vessels as they were severed. Car- 
bolic acid was not used as an antiseptic, as I was apprehen- 
sive that its employment in this locality, and to the extent 
necessary, might lead to troublesome, if not fatal intoxica- 
tion. The liberal and thorough use of salicylated water, 
and the antiseptic compress were effective in preventing 
putrefaction and infection, and thus favored rapid granu- 
lation and cicatrization. The intestinal sutures did not 
hold the parts in apposition until union could take place, 
having cut their way through the intestinal margin in from 
two to three days. Billroth appears to have had the same 
unfavorable experience with such sutures. He says: “To 
draw the rectum down and unite it to the integument inter- 
feres with free drainage ; I therefore do not recommend it. 
The advantage derived from such a course is very slight, as 
primary union hardly ever takes place, but the sutures cut 
through the tissues on the third day, and the rectum re- 
tracts.” A healthy strip of the rectum, corresponding to 
the recto-vaginal wall, was left to prevent, if possible, seri- 
ous stenosis of the rectum. The preparation of the patient, 
and the details of the operation, as well as the after-treat- 
ment adopted in this case, were in accordance with the 
teachings of Volkmann. 
Case II.—Carl K. set. 57, German, farmer by occupation, 
was admitted into the Milwaukee Hospital, November 2, 
1880. His family history presented nothing unfavorable, 
none of his relatives having suffered from any constitutional 
disease. He had always enjoyed good health, but had for 
many years been subject to a hsemorrhoidal affection, which, 
however, caused little uneasiness if the bowels were kept reg- 
ular. Since February last, he has been suffering great pain 
on defecation, and had a great deal of difficulty in procuring 
regular evacuations. The suffering gradually increased, 
and the sensation of obstruction in the lower part of the 
rectum became more acute. He noticed also, that the pass- 
ages from the bowels became smaller and flattened. During 
the last two months the pain during defecation was intense, 
and his general health began to fail, so that for some time 
past, he lias been unable to follow his occupation. At the 5 
time of admission he presented a peculiar, anxious counte- 
nance, was anaemic and somewhat emaciated. He remarked 
that he could endure the suffering no longer, and that lie 
was willing to risk his life in an attempt to even obtain relief. 
On making a rectal examination I discovered a firm, .sharply 
defined tumor, commencing just within the anus and extend- 
ing upwards for three inches ; it occupied more than two- 
thirds of the circumference of the intestine, involving more 
of the left than the right side. It commenced to the right 
of the median line, anteriorly, and terminated at a point 
below, where the anterior half of the right side of the rec- 
tum joins with the posterior half, leaving a narrow strip of 
healthy tissue between. Posteriorly and to the left, the 
tumor was freely moveable with the rectum, showing that 
the neoplasm was limited to the intestinal wall; anteriorly 
it was immoveable on account of the firm attachments of 
the rectum to the urethra, prostate gland, and base of the 
bladder. As the symptoms of obstruction, and,with it, the 
suffering had been rapidly growing worse, excision seemed 
to be the only means that would afford temporary, if not 
permanent relief. The dangers and chances attending it 
were fully explained to the patient, and without hesitation 
he decided in favor of an operation. He was prepared for 
it with the same care as in the preceding case. The incis- 
ions were made in a similar manner ; the dissection between 
the anterior rectal wall and the bladder proved very difficult 
and tedious, the membranous portion of the urethra, the 
prostate gland and neck of the bladder, being fully brought 
into view by it, a sound in the bladder serving as a guide 
during this stage of the operation. The rectum could not 
be brought down, consequently the transverse section was 
attempted with a wire ecraseur, after the example of Mr. 
Cripps, but the wire broke before the division was comple- 
ted. The tissues were then cut through with scissors just 
below the groove made by the wire. The vessels had been 
sufficiently compressed to render this step bloodless. Two 
drainage tubes were introduced after all hemorrhage had 
been arrested, one along the floor of the posterior median 
incision, and the other beneath the urethra and bladder ; 
the space between them was filled up with antiseptic gauze. 
After the wound had been again thoroughly cleansed by 6 
injection of salicyiated water through the drainage-tubes, 
an antiseptic compress was applied which was retained by 
means of a T bandage. The same after-treatment was 
adopted as in the former case ; in the evening the dressing 
was changed, and the patient felt comfortable. 
November 4th. —Visited the patient in the morning, and 
ascertained that, after the last visit in the evening, hemorr- 
hage occurred, the loss of blood amounting to, perhaps, one 
pint, when it ceased spontaneously. 1 found him very pale 
and restless. Pulse, 120; temperature, 102£ degrees; urine 
scanty. The dressing and drainage-tubes were removed, 
and the rectum freely washed out with salicyiated water to 
clear it thoroughly from the small coagula which had re- 
mained in the wound and intestine since the previous even- 
ing. I prescribed Quin, sulph. gr. v., Opii pulv. gr. i.. 
to be taken every four hours. 
November 5th.—Pulse 108; temperature 101 degrees. 
Patient has frequent desires to pass water, and complains 
of great pain during the act. No chill. Has slept but 
little. Prescribed stimulants in addition to the powders. 
November 6th.—Pulse 100; temperature lOOf degrees. 
During the night he has had a severe chill, which was 
followed by intense pain in the abdomen. Tympanites and 
frequent, uncontrollable vomiting. Ordered warm fomen- 
tations and turpentine applied externally, with hypodermic 
injections of Morphia. Although one-quarter grain doses 
of the latter were given every few hours, it was found in- 
efficient to control the pain. Ice and brandy were given to 
arrest the vomiting and sustain the heart’s action, but they 
proved of no avail. The pulse became smaller and increased 
in frequency ; a profuse, clammy perspiration made its ap- 
pearance. the extremities became cold, the face cyanotic, 
the respiration more rapid'and superficial, and he died the 
following morning, with symptoms of exhaustion. 
Remarks.—The unfavorable termination of this case 
may be attributed to two causes, first, the proximity of the 
disease to the bladder and the peritoneum; second, the oc- 
currence of secondary hemorrhage. The peritoneum was 
not injured during the operation, but it was undoubtedly 
exposed to the secretions of the wound. In all probability, 
the hemorrhage took place from that portion of the bowel 7 
which had been constricted by the wire of the ecraseur, and 
afterward severed with the scissors. To my mind, the loss of 
blood was not sufficient to compromise life, but the small co- 
agula which remained in the wound during the night and 
underwent decomposition, may have been a source of in- 
fection, the depleted condition of the blood-vessels, being- 
favorable to the absorption of septic materals. The patient 
was suffering from septic infection the day after the opera- 
tion, and died from septic peritonitis three days subse- 
quently. 
The practical lesson to be learned from this case is, to 
guard carefully against hemorrhage during and after opera- 
tion, and not to permit any blood to remain in the rectum 
or wound for a sufficient length of time to undergo decom- 
position. In case I should again perform a similar operation, 
I should make the transverse section of the intestine with a 
chain ecraseur, or with the galvano-caustic wire. 
There is probably no other disease in surgical nosology 
which produces such intense, and long-continued pain be- 
fore it destroys life than cancer of the rectum. The suffer- 
ing incident to advanced carcinomatous stenosis of the lower 
portion of the intestinal tract is beyond description, and no 
class of patients meet death more gladly and willingly, as 
their only friend, than those suffering from this terrible 
malady. 
While ancient surgeons attacked cancers affecting ex- 
ternal organs with the knife and caustics, in a manner that 
displayed a considerable degree of knowledge and courage, 
they made no attempt to bestow upon the unfortunate 
patients suffering from cancer of the rectum the only means 
of cure or palliation—the operative removal of the diseased 
parts. All the old authors enumerate the rectum among 
the organs which are beyond the reach of the knife or caus- 
tics when affected by this disease. Even Bell remained 
faithful to this doctrine. Speaking of excisions of cancers, 
he says: “ This operation ought never to be advised, where 
the diseased parts are so situated as to prevent them from 
being totally removed, as is the case in cancer of the uterus, 
of the liver, rectum, and some other parts.” (Bell’s Surgery, 
vol. II., page 893.) 
The hesitation on the part, of the older surgeons to con- 8 
for the blessing’s of operative treatment upon patients suf- 
fering from cancerous disease of the rectum, we can only 
explain by assuming that, during their time the knowledge 
of anatomy was very imperfect, pathology was unknown, 
and the instruments crude and illy adapted for performing 
such a difficult and delicate operation. 
The first well authenticated operation of excision of the 
rectum was performed by Faget, in 1739.* In this case the 
rectum had become separated from the neighboring parts by 
two abscesses in the recto-iscliiadic fossa. Faget removed 
a section, an inch and one-lialf in length, consisting of the 
entire circumference of the rectum. • The case progressed 
favorably, defecation proceeding with the new anus as com- 
fortably as in the natural state of the parts. According to 
the assertions of Velpeau, Beclard was the first one to teach 
publicly, (1822,) that for the purpose of removing cancerous 
indurations, the lower portion of the rectum should be ex- 
tirpated. Four years later, Lisfranc performed the first 
operation for malignant disease of the rectum. He made 
many careful dissections to show that the lower portion of 
the bowel could be excised without opening the peritoneal 
cavity. He gave the distance from the anus to the perito- 
neum in the male as 108 mm., and in the female as 162mm. 
A few years later, Blandin studied the same subject, and 
arrived at opposite conclusions. He found that in the fe- 
male the peritoneum is only 41 mm. distant from the anus, 
and in the male 81 mm., while, in the foetus and in small 
children, it descends much lower, so that in them no recto- 
vaginal, or recto-vesical wall is found. Among nine oper- 
ations performed by Lisfranc, previous to 1831, five termin- 
ated in recovery, in one instance the result was doubtful, 
and three cases ended fatally. The cause of death in two 
cases was purulent effusion into the pelvis, and phlebitis; 
the body of the third subject was not examined. 
In Germany Lisfranc found an enthusiastic follower in 
Dieffenbach, who, it is said, operated over thirty times. 
It is reasonable to suppose that the pupils of these eminent 
surgeons and popular teachers readily adopted the operation 
and soon carried it to extremes, which could not fail in be- 
ing productive of disastrous consequences which dragged 
* Walslie on Cancer, Boston, 1844, page 277. it from the sphere of propriety and usefulness into disgrace 
and abandonment. For years the operation remained in 
disrepute among surgeons until it became revived by Volk- 
mann and Nussbaum, in Gernany, Koclier, in Switzerland, 
and Cripps, in England. These men, and many others, 
have improved the methods of operation, and have elevated 
the procedure to a scientific and legitimate one—a blessing 
to suffering humanity, and a triumph to the art and science 
of surgery. Although the operation is endorsed by many 
of the ablest surgeons, it has still its opponents, among 
them men of distinction and eminence. For the purpose of 
ascertaining the voice of the profession, pro and con.,I will 
briefly quote from a. few authorities. Mr. H. Smith * dis- 
poses of this subject briefly in the following words : “Some 
surgeons were, a few years since, in the habit of perform- 
i ng excision of the lower part of the rectum when affected 
with cancer, but this proceeding must be looked upon as 
both barbarous and unscientific, and it is now happily ex- 
cluded from the catalogue of surgical operations.” Profes- 
sor Gross f looks upon the operation simply as a palliative 
measure, the temporary benefit to be derived from it hardly 
justifying the exposure of the patient to the dangers inci- 
dent to its performance. He says : “ Excision promises no 
benefit in this disease, save temporary relief from pain and 
bocal obstruction. When the anus is involved, the opera- 
tion must, of course, include the sphincter muscles, thereby 
depriving the patient of the power of controlling his pas- 
sages, and the same result would be sure to follow the ex- 
cision of a portion of the rectum, to say nothing, in the 
latter case, of the immediate risk of life from hemorrhage, 
peritonitis, and phlebitis.” 
Erichsenj; condemns the operation in the following, by no 
means flattering, terms: “The recommendation to excise 
the cancerous mass, as made by Lisfranc and other French 
surgeons, is contrary to every principle of good surgery, 
as it is impossible to extirpate the whole of the disease 
without either laying open the peritoneal cavity, or destroy- 
ing the patient by the profuse hemorrhage which could 
scarcely be arrested.” 
* Holmes’ System of Surgery, Vol. IV., page 858. 
t System of Surgery, Pliila., 1864, Yol. II., page 301. 
X The Science and Art of Surgery, Pliila., 1809, page 1,007. 10 
Hamilton* discountenances excision when the disease is 
located above the sphincters, and doubts the veracity of the 
accounts of cases which have been reported as cured. He 
says: “ Epithelioma and scirrhus occurring above the 
sphincters are not, in my judgment, curable by any surgi- 
cal operation. Cures have been reported after the removal 
of large portions of the rectum for both epithelioma and 
scirrhus, but not upon reliable authority.” 
Against this formidable array of opponents to the oper- 
ation, I will record the opinions of a few eminent surgeons 
who favor it. The opposition to the operative treatment 
of cancer of the rectum comes mostly from England and 
America. German and French surgeons, as a rule, look 
upon it as a legitimate and scientific procedure. 
Volkmann, t who has done more than any other surgeon 
towards rendering the operation free from danger, by the 
application of antiseptic precautions during and after its 
performance, makes the following statement: “To the 
capital operations in which, for the last few years, I have 
been successful in reducing materially the former mortal- 
ity, by the gradual improvement of the methods of opera- 
tion, and especially by adopting a better treatment of 
wounds, I may add more particularly the operative re- 
moval of malignant growths of the rectum, and extirpa- 
tion of the rectum. Although at present I am not pre- 
pared to prove my assertions with figures, yet I can state 
that formerly I lost a relatively large percentage of those 
operated upon, while now it is seldom that one dies from the 
operation, notwithstanding that at present I give the oper- 
ation a. wider range of application than before, and I am 
not even afraid of an accident or unavoidable opening into 
the peritoneal cavity during its performance. During the 
first few years of my service as a clinical teacher, I lost 
every case where this accident occurred unintentionally; 
during the last fi ve years all such cases recovered, without 
exception. The most important part of the treatment con- 
sists in the careful and effective drainage of the wound, 
combined with an equally careful primary disinfection, fol- 
lowed by frequent antiseptic irrigation.” 
* The Principles and Practice of Surgery, N. Y., 1878, page 776. 
f Sammlung clinisclier Yortrfige, Chirurgie, Yol, IL, page 1,112. Esmarch,* who has made the treatment of cancer a 
careful study for a number of years, is in favor of the op- 
eration, as may be seen from the following language : “ In 
the treatment of cancer of the rectum the same principles 
are to be observed as when the disease affects other parts 
of the body. Extirpation must be practiced as early as 
possible, and the more of the adjacent healthy tissue is re- 
moved with the growth, the greater is the probability that 
a relapse will not take place at all, or at least after a long 
period of immunity. The prognosis is the most favorable 
when the disease affects the anus, or the lowest portion of 
the rectum.” 
Koenigf makes the following common-sense remarks in 
speaking of the treatment of malignant diseases of the 
rectum : “ There is absolutely no reason why neoplasms of 
the rectum should be treated differently from those in other 
parts of the body; on the contrary, cancer of the rectum, 
which is the cause of such excruciating pain in patients 
suffering from this disease, calls more emphatically for an 
operation. We must mention this particularly, inasmuch 
as distinguished surgeons, especially in England, are op- 
posed to an operation. If we can only operate in healthy 
tissue, we succeed not infrequently in keeping these poor, 
tortured patients for many years free from pain. And, 
although the unfavorable anatomical relations of the parts 
render a relapse probable, an operation affords palliation, 
for a time at least. ” 
Nussbaum,j; whose opinion in anything pertaining to 
operative surgery must always be considered as authorita- 
tive, is an enthusiastic advocate of the operation, as may 
be learned from the introductory remarks to the report of 
his remarkable case of excision of the rectum, part of the 
urethra, entire prostate gland, and neck of the bladder for 
malignant disease. “In the month of August, 1863, I re- 
ported in this journal four cases, which demonstrate that 
the removal of a carcinomatous rectum is a beneficial oper- 
ation, calculated to prolong life, and to afford comfort to 
the patient. These cases proved that an operation on the 
*Neubildnngen des Mastdarms. Billroth und Pitha, Handbuch der 
allg. u. speciellen Chir., vol. ii., p. 186. 
fLehrbuch der speciellen Chirurgie, Berlin, J879, vol. ii., p. 301. 
jSeparat Abzng des aerztlichen Intelligenzblattes, No. 44. 12 
rectum may be undertaken even when the bladder of the 
male, or the vagina of the female are, to a greater or less 
extent, involved by the cancer. On that occasion I could 
have mentioned cases of operation for cancer of the rectum 
where patients were almost moribund, and yet recovered 
after the operation, and lived for months and years subse- 
quently, happy and contented until at last an ugly relapse 
produced the former complaints and dangers, and which 
were no longer amenable to the operative treatment. I 
have repeatedly removed pieces of the male bladder of the 
size of a silver dollar, with the diseased mass, and the 
wound healed cempletely, like that after lithotomy, with- 
out leaving a urinary fistula, and the relapses appeared very 
late, because rectal cancer, if removed by incision through 
healthy tissue, returns much later than many other can- 
cers.” 
Dr. John B. Roberts45' closes an excellent paper on rectal 
cancer, as follows : ‘ ‘ The success attending the operations 
has not been invariable, but enough so, I think, to show 
that in selected cases the operation can be done with a rea- 
sonable hope of alleviating the distress of the patient, and 
making life endurable. It should be done in the earliest 
stages of the disease.” 
Dr. Chas. B. Kelsey, of New York, says:f “In a small 
number of selected cases a cure is perhaps possible, as with 
cancer of feeble malignancy in other parts of the body, e, 
g., epithelioma of the lip. At all events, the disease may 
be removed and its return delayed for many years. This 
fact, we believe, may be accepted as proved by a sufficient 
number of carefully examined cases, from which the chances 
of error in diagnosis and subsequent history have been eli- 
minated.” 
As such a great diversity of opinion prevails among 
surgeons in regard to the propriety and utility of excision 
of the rectum for malignant disease, it may be well to in- 
quire what have been the results after this operation, in sav- 
ing life and diminishing suffering. 
Five out of nine cases operated upon by Lisfranc re- 
covered. Dieffenbach claimed that a large proportion of 
the thirty cases of his own, recovered and remained com- 
*Surgery in the Pennsylvania Hospital, Phila., 1880. 
f American Journal Med. Sciences, Oct.., 1880. 13 
fortable for a number of years. Billroth examined a 
woman fifty-one years of age who had been operated upon 
by Sehuh four years previously, and was unable to find a 
sign of relapse, although the cancer had reached high up in 
the intestine, and embraced its entire circumference. Bill- 
roth * himself extirpated the rectum thirty-three times— 
thirty-two times for cancer, once for melanotic sarcoma. Of 
this number twenty survived the operation; the majority of 
them, however, died within one or two years after the 
operation from a return of the disease. Thirteen of the 
patients died in consequence of the operation, a mortality 
of 39.3 per cent. Death was attributable in every instance 
to retro-peritoneal phlegmonous inflammation, which in 
most cases assumed an acute septic character, proving fatal 
from the fourth to the eighth day. 
VolKmann has had three permanent cures among his 
cases of rectum extirpation, and a number of cases where 
the disease returned after a long time. This occurred in one 
case after six years, once after five years, and once after 
three years. One of his patients died after eight years, with- 
out a local return of the disease, from cancer of the liver. 
One of his patients remained well after eleven years from 
the time the rectum was extirpated, having in the mean- 
time submitted twice to the removal of cancerous nodules 
in the neighborhood of the newly constructed anus. 
Kocher f reports ten cases of excision of the rectum, of 
which eight survived the operation, and two died from sep- 
tic periproctitis and secondary peritonitis eight days after 
the operation. Four cases were under observation, re- 
spectively, for three and a half, four and three-quarters, 
seven and eight years without suffering from a relapse. The 
remaining patients died from a return of the disease from a 
few months to four years after the operation. 
Among the many cases of excision of the rectum report- 
ed by Nussbaum, one deserves special mention. The 
patient had been suffering from cancer of the rectum for a 
long time, and his strength had been greatly reduced by 
frequent copious hemorrhages, He had often passed blood 
with the urine, and for sixteen days had no passage from 
the bowels, owing to cancerous constriction in lower portion 
* Chimrg. Klinik, Berlin, 1879, p. 260. 
t Deutsche Zeitselirift, fiir Chirutgie, vol. xii, p. 159. 14 
of the gut. On forcing the index finger through the strict- 
ure, blood escaped freely through the urethra, showing that 
a communication existed between the rectum and urethra. 
A careful examination with the catheter revealed the fact 
that a part of the urethra, the entire prostate glands, the 
neck of the bladder and nearly four inches of the rectum 
were affected with the neoplasm. As all other means ad- 
opted to afford relief entirely failed, an operation was re- 
lucantly performed at the patient’s urgent request. The 
anus was circumscribed by two semilunar incisions; the dis- 
section continued upwards along the sides of the bowel to a 
distance of four inches, when healthy tissue was reached. 
After the affected portion of the urethra, the prostate 
gland and neck of the bladder were cut away from the 
healthy tissues, the healthy bowel was drawn downwards to 
the external wound, and the diseased part separated with 
the knife. At this step of the operation a large quantity of 
faeces escaped. The intestine was sutured to the skin by 
means of ten interrupted sutures, and the remaining wound 
closed with four sutures, after the introduction of a gum 
elastic catheter along the intestine, through the perineum, 
into the bladder. The bleeding was profuse, but was con- 
trolled by four ligatures and ice-water. The patient, almost 
moribund after the operation, rallied on administration of 
stimulants. During the first few days active febrile action 
took place, with a temperature of 40g C., and a pulse of 
from 130 to 140. Sensations of chilliness were followed by 
well marked chills. The catheter could no longer be 
tolerated, and several sutures were removed from the peri- 
neal wound to favor drainage. From this time improve- 
ment commenced to take place. On the fifth day secondary 
hemorrhage occurred, which was arrested by means of a 
charpie tampon in the rectum. The intestine united with 
the wound, except at a point in front where the sutures 
tore through. At this place the urine entered the rectum 
and escaped through the newly made anus. The wound 
healed rapidly, and during the process of healing a valve- 
like closure was effected between the bladder and rectum, 
so that the urine escaped every twenty to thirty minutes 
into the rectum, but the contents of the latter were prevent- 
ed from entering the bladder. This arrangement afforded 
great comfort and convenience to the patient. He recovered 
sufficiently to be able to follow his occupation as a black- smith, and enjoyed life for three years, when he succumbed 
to a local relapse of the disease. This case would certainly 
tend to show that an operation may be indicated and prove 
beneficial even in cases whicli would seem to be beyond the 
reach of surgery. 
Of five cases operated upon by Prof. Schoenborn,* four 
recovered and one died. In the fatal case the peritoneal 
cavity was opened, and the wound closed by sutures. On 
post-mortem examination no evidences of peritonitis were 
apparent. In one case that recovered, a woman 73 years of 
age, the peritoneal cavity was also opened, and had to be 
closed with seven sutures. She recovered completely from 
the operation, and died three and a. half years later from 
senile marasmus. 
Cripps, of the Great Northern Hospital, has excised the 
rectum five times without fatal result, and has assisted at 
thirteen more operations, of which two of the patients died 
from the direct results of the operation, one from peritoni- 
tis, and one from collapse, making a total of eighteen opera- 
tions with two deaths. According to Agnew,f this opera- 
tion has been performed ten times in this country, of which 
number two were done by Bushe, one by Mott, one by 
March, one by Bridden, three by one by J. R. Wood, 
and one by Agnew. Of these cases three were successful, 
one died seven months after the operation with what was 
said to be consumption, one lived sixteen months after the 
operation, in one the termination is not known, and four 
died as the direct result of the opera tion. To this number 
may be added the cases of Byron:}; and Post,§ both of which 
terminated favorably, and the two of my own, making a 
total of 14 cases with six deaths. 
Dr. Kelsey || has recently published an analysis of 140 
cases of excision of the rectum for malignant disease, of 
which number 22 died, death being attributable directly to 
the surgical interference. The causes of death were : peri- 
* Deutsche Zeitshcrift fur Chirurgie, vol. xiii., Heft 5 und 6. 
f Principles and Practice of Surgery, Phila., 1878, vol. 1, p. 435. 
J Annals of the Anatom, and Surg. Society, May, 1880. 
g The N. Y. Med. Record, July 31, 1880. 
|| N. Y. Med. Journal, Dec. 18S0. 16 
tonitis, 10; pelvic cellulitis and phlebitis, 4; septicaemia, 3; 
exhaustion, 3; hemorrhage, 1; erysipelas, 1. 
Six of the cases remained permanently cured after a pe- 
riod of at least ten years. In twenty-four cases life was 
prolonged from one to six years without a return of the dis- 
ease. In thirty-five cases where the fact of recidivation is 
mentioned, there was a local return in nine within three 
months, in nine within six months, in eleven within one 
year, in four within a. year and one-half, and in three with- 
in two years. 
Considering all cases collectively, the results obtained by 
the operation must certainly be regarded as satisfactory, 
both as a. curative and especially as a palliative measure, 
comparing favorably with any other operation for cancer, if 
we exclude epithelioma of the lip. If we take into account 
the hopeless condition of patients suffering from rectal can- 
cer and the excruciating pain attending its progress, we are 
justified in our efforts to procure alleviation at almost any 
risk. Cancer of the rectum in the great majority of cases 
belongs to the epithelial variety ; hence, if excised early and 
thoroughly in exceptional cases does not return, or at least 
only after a long period of immunity from physical pain and 
mental distress. It may be laid down as a rule that exci- 
sion should be practised as soon as a diagnosis of cancer can 
be made, and that it is admissible, unless contra-indicated 
by serious complications, as long as the neoplasm is lim- 
ited to the walls of the intestine and the upper margin re- 
mains within reach of the index-finger. In most instances 
it will be found advisable to remove the sphincter ani mus- 
cles with the diseased mass, as observation has shown that 
the so-called sphincter tertius presents complete faecal in- 
continence. It is my firm conviction that where death fol- 
lows surgical interference it is attributable, in the majority 
of cases, to septic infection, hence every precaution should 
be taken—before, during, and after the operation—to 
guard against this occurrence by securing free drainage and 
preventing putrefaction of the products of the wound by 
the employment of safe and reliable antiseptics.