THE 
SURGICAL TREATMENT 
OF— 
CANCER OE THE RECTUM. 
BY 
CHARLES B. KELSEY, M. D. 
SURGEON TO THE INFIRMARY FOR DISEASES OP THE RECTUM, N. T. ; 
LATE ASSISTANT DEMONSTRATOR OF ANATOMY AT THE COLLEGE 
OP PHYSICIANS AND SURGEONS, N. Y. ; MEMBER OF THE NEW 
YORK COUNTY MEDICAL SOCIETY ; THE NEW YORK 
CLINICAL SOCIETY, ETC., ETC. 
REPRINTED FROM THE AMERICAN JOURNAL OP THE 
MEDICAL SCIENCES, OCTOBER, 1880. CANCER OF THE RECTUM. 
The treatment of malignant disease of the rectum is designed to be 
either curative or palliative. 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 eliminated. Cure can, however, only be effected by excision. 
All other means may be set aside as hopeless failures. 
The operation of excision, which after being fully described and ably 
advocated by Lisfranc in 1830 was allowed to fall into disuse, has again 
within the past few years become popular. It would probably be a waste 
of time to inquire to whom the credit of reviving it is due. Cases of its 
occasional performance are scattered through the surgical literature of the 
rectum from the early part of the century to the present, and just now it 
is at the height of its popularity. Like every other surgical procedure at 
that point of its history, it is perhaps also occasionally done when it were 
better to be content with less radical measures. As a result of a careful 
search among the statistics of this operation, Cripps1 gives the following 
figures. Out of a total of sixty-four cases, eleven died as a direct result 
of the operation; six from peritonitis, one from cellulitis, and four from 
accidents incident upon any surgical interference. There is but little doubt 
that this mortality might be reduced by a more careful selection of cases, 
as in the six cases of death from peritonitis, the peritoneum was opened 
in three, and in the other three the disease reached fully three inches from 
the anus. The height to which it is safe to go in this operation cannot be 
definitely stated for all cases, the reflection of the serous coat upon the 
rectum being at a variable point. Fochier2 reports a case in which he 
used the ecraseur at twelve centimetres without harm, and Allingham,3 
who is always a safe guide, has seen all but the lower two inches of the 
bowel covered by peritoneum in a female, has opened into it in a male 
when not more than three and one-half inches were removed, and has 
1 Cancer of the Rectum, London, 1880, p. 166. 
2 Lyon Med., Feb. 20, 1876. 
8 Diseases of the Rectum, Ed. of 1879, p. 275. taken away fully five inches in a male without bringing it into view. We 
can only say that the danger increases with every line above three inches. 
In the fifty-three cases of recovery the subsequent history is unknown in 
sixteen, and in three more the diagnosis was so doubtful as to exclude 
them from the list. No case is worth much in the consideration of a 
question such as this where the diagnosis has not been verified by the 
microscope in competent hands; for there are non-malignant growths of 
this part, which, to the naked eye, strongly resemble cancer. We have 
then a remainder of thirty-four, in Avhom the disease returned in twenty; 
but of these twenty several were operated on a second time for a recur- 
rence of the growth, or possibly for a small nodule which had not been 
removed at the first operation, and after this second operation remained 
free. This leaves, however, a total of twenty-three out of sixty-four 
operations in which the disease had not returned after an interval varying 
from a few months to over four years—a limit reached in three cases. 
This is certainly an encouraging result for this disease, and the fact that 
undoubted cancer may be removed and not reappear for such a length of 
time is decisive. Some operators, however, report better results than 
these, and some have not been so successful. Curling1 gives one case of 
removal of an epithelioma in -which there had been no return in the rectum 
after seven years, though for one year there had been “a doubtful tumor 
of the pelvis.” Velpeau and Vernouil each report cases in which the cure 
has seemed permanent, and Chassaignac gives several in which there had 
been no return after six years. Diefienbach’s thirty cases in which the 
patients lived many years without a return are generally looked upon with 
suspicion. Allinghara,* on the contrary, considers the partial removal of 
the circumference of the bowel as unsatisfactory. In all of his thirteen 
cases in which he was able to follow the progress of the case for one year, 
there was either a return of the growth in the rectum or the glands in the 
groin became affected and there ensued disease in the internal organs. In 
four cases the disease did not return in the bowel but in the inguinal 
glands, proving that it was not due to an incomplete operation. With 
regard also to his ten cases of total extirpation he speaks very cautiously. 
He believes that a cure is very uncommon and not generally to be ex- 
pected ; and he does not commit himself even on the question of the pro- 
longation of life. The mortality, as a direct result of the operation, is 
generally about twenty-five per cent.* 
Since then, in certain cases, we are justified in expecting recovery from 
the operation itself and such a length of life as would not result where the 
disease left to its natural course, we may ask to what cases is it applicable ? 
1 Diseases of the Rectum, Ed. of 1876, p. 164. 
* Loc. cit., p. 277. 
s Molliere, Traite des Maladies du Eectum et del’Anus, Paris, 1817, p. 627. what are the methods of its performance ? and what the after results as 
regards the condition of the bowel ? Unfortunately we rarely meet the 
disease at a stage when extirpation is justifiable, that is, when it is limited 
to a circumscribed spot within three or three and one half inches of the 
anus, when it is movable on the muscular coat, and has not invaded the 
deeper tissues, and before the neighboring glands are enlarged. Dr. L. A. 
Stimson’s1 study of cases is very valuable in this connection. He bases 
the prognosis as to immediate return far more upon such naked-eye 
appearances as these than upon the microscopic character of the growth. 
We should certainly not consider it advisable, as has recently been done, 
to attempt excision in a case where the peritoneum was deliberately opened 
in a woman, it being palpably impossible to extirpate the growth without 
cutting into that cavity. The prospect of prolonging life is not sufficient 
to compensate for the danger of immediate death, or of certain local return. 
The operation has once been abandoned and will certainly be so again 
unless it is kept within narrower limits than these. 
There are many ways in which the rectum may bo wholly or partially 
removed, but it does not fall within the scope of this article to describe 
them in detail. The knife, ecraseur, elastic ligature, or the galvano- 
cautery may be used, and each operator has his favorite method. The 
rectum may be freely laid open by a deep, posterior, median incision as a 
preparatory step, and the two sides dissected up laterally from this as a 
starting point; or two elliptical incisions may be made surrounding the 
anus, and the dissection carried along the bowel from without inwards. 
The ligature and galvano-cautery are chiefly in favor as means of avoiding 
hemorrhage; but, though hemorrhage is one of the things to be looked 
after, the main requisite in controlling it is plenty of room, and this is 
best obtained by the posterior incision through rectum and anus nearly to 
the tip of the coccyx. This cut greatly facilitates the performance of the 
operation, and, moreover, allows free drainage subsequently. The acci- 
dents most to be feared are opening the peritoneum and wounding neigh- 
boring viscera, and in avoiding these, the advantages of a careful and, if 
necessary, deliberate dissection with the knife over the ecraseur or cautery 
are manifest. In the female the recto-vaginal septum may be removed to 
a considerable extent without interfering with the good result, but a wound 
of the vesicuifc seminales or base of the bladder in the male is not so light 
a matter. 
With regard to the condition of the parts after operation, two opposite 
conditions are to be feared, stricture and incontinence of feces. The 
former may be met by dilatation, and the latter is not a contraindication to 
the operation. Experience on this point is almost unanimous, Allingham 
1 A Contribution to the Study of Cancer of the Rectum, “Arch, of Med.,” Aug. 1879. being the only author vdio seems not to have had satisfactory results. It 
is certain that the whole sphincter muscle may be removed and the patient 
recover a comfortable degree of control over everything except fluid 
motions. This is due to the greater or less degree of contraction which 
always follows ; to the action of the mucous membrane which may become 
more or less prolapsed and act as a valve; to the fact that a few fibres of 
the sphincter may have been left; to the thickening of the muscular tissue 
at the lower end forming a rudimentary sphincter ; and to the physiological 
fact that the sigmoid flexure is the reservoir of feces, and that normally 
the rectum is an empty pouch, only filled at the time of defecation. Bear- 
ing this point in mind, it is easy to understand how the sphincter may be 
dispensed with, and no other explanation seems so well to account for what 
is an undoubted clinical fact. 
The palliative treatment of cancer of the rectum is directed chiefly to- 
ward fulfilling three indications: 1. Relief of pain; 2. Overcoming ob- 
struction; 3, Cleanliness, We shall consider each of these in its order. 
The pain in this affection depends on two classes of causes—those which 
make cancer a painful disease wherever mot with in the body, and those 
which are due solely to its situation at the outlet of the bowel. Among 
the first, we have pressure upon adjacent parts and involvement of neigh- 
boring organs and nerves; and among the second, the passage of feces 
over an ulcerated surface and spasm of the sphincter muscle from irrita- 
tion caused by its direct implication in the cancerous growth, or by the 
passage over it of irritating sanious discharges from the sore. From this 
it is easy to understand why cancer is in one person attended by excru- 
ciating suffering, while another may hardly be conscious of its presence; 
and why the pain is in some paroxysmal and particularly aggravated by a 
movement of the bowels, and in others dull and constant, radiating through 
the loins and down the thighs. For the relief of this symptom we have 
at our command: a. Regulation of the passage, diet, and the recumbent 
posture; b. Anodynes locally and by the mouth; c. Partial destruction 
of the growth by means of the curette, cauterization, or partial extirpa- 
tion; d. Division of the sphincter; e. Lumbar colotomy. 
The passages should be kept soft but not fluid, as any approach to diar- 
rhoea always aggravates the suffering. This may be done partly by the 
choice of food, which needs to be regulated with great care on account of 
the tendency to gastric disturbance, more or less of which is always pre- 
sent ; and by the administration of the mineral waters, which are generally 
sufficiently laxative for the purpose. Rest in the recumbent posture is a 
means of palliation of great value, sometimes giving more relief than ano- 
dynes. These latter may be given both by the mouth and in enemata, 
and if possible should be pushed to the point of relieving suffering. This 
seems so plain a duty which the surgeon owes to his patient that we need not stop to discuss any possible moral bearing it may have. If the agony 
of this incurable malady could always be relieved by the administration of 
opium, the question of operative interference would arise much less fre- 
quently than it now does. But, unfortunately, the constant administra- 
tion of this or any other narcotic will sometimes cause gastric and mental 
disturbance harder to bear than the disease. By using the finger-nail, a 
curette similar to the one used in the uterus, or a scoop such as is used for 
submucous uterine tumors, the pain may in some cases be greatly re- 
lieved by a removal of a part of the growth when of the soft variety. The 
same may be done by the application of chemically destructive agents or 
the actual cautery, and even by the partial excision of the mass, merely as 
a means of relief and where there is no question of cure. 
In a previous paperl I have already called attention to division of the 
sphincter muscle, as a palliative measure in the treatment of rectal dis- 
ease. and have tried to show that the pain in malignant growths was often 
due in a great measure to its spasmodic action, and might be permanently 
relieved by its complete division. That the operation itself was devoid 
of danger, and that its results in proper cases fully equalled those of the 
more dangerous operation of lumbar colotomy, was also proved; and an 
attempt was made to reduce this operation, whose good results wore first 
shown by the French surgeons, to a definite rank among the means at our 
control for the treatment of painful affections of this part. 
I see that Allingham in his last edition, also adds his testimony in 
favor of the value of the operation, which may be performed in several 
ways, all having the complete division and paralysis of the muscle in view; 
and is absolutely indicated in all cases where the muscle is found firm, 
irritable, and inclined to spasm. In such cases the relief of suffering will 
sometimes be so great as to deceive the patient into the belief that his 
cancer has been radically cured, though it has not in reality been touched. 
There is a class of cases in which the sphincter will be found in a condi- 
tion exactly the opposite of this—relaxed, patulous, admitting readily the 
larger blade of Sims’ speculum. In such the disease will generally be 
found well up the rectum, and probably by its pressure has paralyzed the 
nerves which supply the muscle. Here the operation can give no relief. 
We come now to the dernier ressort of surgery for the relief of pain— 
lumbar colotomy, and there are several points in connection with it which 
should be well borne in mind. We may ask, 1, to what cases is it appli- 
cable ? 2, what is the danger to life in its performance ? 3, what hope of 
prolonging life does it give? Taking these questions in their order, we 
should say it was applicable only to those cases in which the pain may 
reasonably be supposed to be entirely or in great part due to the direct 
1 Division of the Sphincter Ani Muscle as a Therapeutic Measure. New York Med. 
Journ,, June, 1880. contact of the feces Avith the diseased surface. There are such cases, and 
in them the operation accomplishes what no other means will, and the 
sufferer feels amply repaid for having submitted to it if he lives hut a few 
weeks in comfort; hut such cases are not common—not so common, we 
submit, as is the performance of lumbar colotomy. If one were to judge 
from the published reports of this operation which appear from time to time 
in the current journals, he might suppose that the mere diagnosis of a can- 
cer of the rectum avus in itself a sufficient reason why the sufferer should at 
once be furnished Avith an artificial anus. There could be no greater error 
and the operation is often done Avithout affording any relief, and perhaps 
in cases Avhere such a result might have reasonably been anticipated. We 
have placed it last on the list of knoAvn methods of relieving pain, and 
have called it the dernier rassort, and such it is. When none of the other 
means Ave have mentioned serve to make life comfortable it is time to 
consider whether this one is likely to. As to the immediate risks of the 
operation statistics are difficult to obtain. Bryant, in fifteen cases for 
various diseases, gives one death from peritonitis, and two Avithin the first 
three days, “the operation having been undertaken too late.” Curling in 
twenty-one cases has had seven fatal results, two from chloroform, one in 
Avhich peritonitis already existed, one from pyaemia, two from exhaustion, 
and one from a peritonitis Avhich sprang from the disease and not from the 
wound. Allingham in tAventy-seven cases lias had no deaths which could 
properly be attributed to the operation'; a fact probably due to the care 
with Avhich his cases Avere selected. In fact such figures as these slioav 
better than avouM any elaborate tables the dangers of the operation. In 
properly selected cases the immediate danger is peritonitis, not a very 
great one, and, in addition, the accident of not finding the part of the 
boAvel intended—a thing Avhich has often happened to the best operators. 
If the operation is attempted Avhen the patient is too Aveak to bear the 
anaesthetic, or is in the last stage of exhaustion, the mortality must of 
necessity bo great. As to prolonging life, Avhen the patient is in danger 
of immediate death from obstruction this may be done; also Avhen death 
is imminent from the intensity of the suffering, a few Aveeks or months may 
be gained in Avhich the cachexia shall run its natural course. But the 
average length of life in cancer of the rectum is not much over one year 
from the time the patient generally comes fairly under observation of the 
surgeon, and Avhether lumbar colotomy be done early or late the time 
Avhen life shall yield to the gradually advancing cachexia Avill not be much 
affected. 
For overcoming obstruction—the second indication in palliative treat- 
ment—Ave again find numerous moans at our disposal. These may be 
grouped under the following general heads: I, dilatation; 2, division; 
3, destruction ; 4, lumbar colotomy. Before commencing to treat the ob struction as such, it is well to remember that an exceedingly small outlet 
to the alimentary canal may, with proper care, be made to answer all the 
calls of nature. We see this constantly in cases of stricture both simple 
and malignant, where the finger cannot be forced through the obstruction, 
and yet there is no retention ; and in such cases by the judicious admin- 
istration of laxatives life may be made so comfortable that the question of 
surgical interference shall be postponed indefinitely. When, however, 
dilatation becomes necessary, it should be of the gentlest kind. The cases 
of fatal accident from perforation of the bowel where the coats have been 
Aveakened by ulceration are already numerous enough to serve as warnings 
for all future time. The best of all dilators in cancerous disease is the 
finger, either that of the patient or the nurse, passed daily; and none of 
the mechanical means with which we are acquainted equals this for safety 
and comfort. If dilatation be found too painful or ineffectual, as it sometimes 
will, recourse may be had to division of the stricture. 
Under the term rectotomy many different procedures are included,1 such 
as nicking the stricture at one or several points ; free division in the me- 
dian line by a single deep incision either anteriorly or posteriorly or both ; 
division of the stricture and of all the parts below, including the anus, 
with the knife, ecraseur, or thermo-cautery (external rectotomy of Ver- 
neuil), etc. The latter is the most radical and the safest of all. for -the 
reason that it permits free drainage and discharge of fluids. Instead of 
this, attempts may be made at opening a passage by the destruction of 
a part of the growth, as has been explained in speaking of the relief of 
pain. 
There is no constriction within four inches of the anus which may not 
be overcome by some one or other of these means. What then remains 
for lumbar colotomy? Simply those above the reflexion of the peri- 
toneum. We have tried to show with regard to this operation that it 
should be a last resort; that there are many simpler means at the hand 
of the surgeon for accomplishing what it is intended to accomplish; that 
it is at best simply a palliative measure, and one by no means devoid of 
danger; and that the cases in which it is likely to be justified by results 
may be selected with considerable certainty beforehand. 
The last indication to be met is cleanliness, and this will be found neces- 
sary chiefly in those cases where from extensive ulceration the anus has 
been destroyed, and the whole rectal pouch converted into an open sore. 
There is nothing better perhaps as a disinfectant in such a case than a 
weak solution of permanganate of potash, or where the discharge contains 
much blood, one of the usual astringents. 
1 See article by author in N. T. Med. Jour,, March, 1880. 
No. 48 East Thirtieth Street, New sTork.