REPORT 
OF 
TWO OASES 
OF 
EXCISION OF THE RECTUM, 
WITH REMARKS. 
A. VAN DERVEER, M.D., 
BY 
PROFESSOR PRINCIPLES AND PRACTICE OF SURGERY IN ALBANY 
MEDICAL COLLEGE; ATTENDING SURGEON AT ALBANY 
AND ST. PETER'S HOSPITALS, ETC. 
(Abstract of paper read at the Semi-monthly Meeting, 
Albany County Medical Society.) 
Reprinted from The Medical Record 
September 12 th, 1879. 
NEW YORK: 
WILLIAM WOOD & COMPANY 
1879. REPORT 
OF 
TWO CASES 
OF 
EXCISION OF THE RECTUM, 
WITH REMARKS. 
BY 
A. VAX DERVEER, M.D., 
PROFESSOR PRINCIPLES AND PRACTICE OF SURGERY IN ALBANY 
MEDICAL COLLEGE; ATTENDING SURGEON AT ALBANY 
AND ST. PETER’S HOSPITALS, ETC. 
(Abstract of paper read at the Semi-monthly Meeting, 
Albany County Medical Society.) 
Reprinted from The Medical Record, 
September 12 th, 1879. 
WILLIAM WOOD & COMPANY. 
NEW YORK*,: 
1879. REPORT OF TWO CASES OF EXCISION 
OF THE RECTUM, WITH REMARKS. 
That excision of the rectum is not a very difficult 
operation has been shown by the success of several 
operators. Billroth is said to have performed it six- 
teen times, twelve of his cases making good recov- 
eries. 
Among the first to do the operation in this section 
was the late Dr. March, who operated upon a female 
patient in 1868. Site made a good recovery, living 
for eighteen months, and then died from a rapid re- 
turn of the cancerous disease. 
Dr. John B Roberts, of Philadelphia, has contrib- 
uted a valuable paper on this subject. 
Of ten cases reported as operated on in this coun- 
try, four are known to have died. One died seven 
months after operation, of what was said to be con- 
sumption ; one was living sixteen months after the 
excision; of one, the termination is not known, and 
three are cured. 
In a report by Schmidt, of Leipsic, out of thirty- 
three cases, twenty are reported cured. 
Case I.—Removal of lower portion of rectum for 
villous form of carcinoma about the anus.—Mrs. W , 
aged forty, married, and the mother of four children. 
She has always been in fair health, and presents a 
good family record. In the spring of 1877, her 4 
youngest child being three years old and her men- 
struation regular, she noticed an irritation about the 
anus, which gave her great annoyance, and at times 
pain. Her bowels became more constipated than 
usual, and she had some distress in passing urine. 
By June 1st she noticed a growth about the opening 
of the bowel, which she at the time believed to be 
piles, and accordingly consulted a specialist in this 
city for the treatment of that disease. She was now 
suffering much pain and itching, and was frequently 
compelled to take anodynes in order to get rest at 
night. The movement of her bowels she very much 
dreaded, as it gave her increased pain and distress. 
There was a constant moisture about the anus and 
perineum. The discharge was offensive, being ichor- 
ous in character, and producing an eruption about 
the skin of the gluteal regions. 
The treatment she received gave her but little relief, 
and on Sept. 20, 1877, I was consulted. She now 
presented a pale, anxious expression of countenance, 
was in constant pain, her bowels being at times in a 
condition of diarrhoea; again they were costive, 
giving her greater pain. There was a loss of appetite 
and flesh. Her urine was in a healthy state—very 
little leucorrhoea. The uterus and organs of the pel- 
vis were all in a healthy condition. No induration 
or inflammation of the deep or superficial inguinal 
glands. About the anus was a warty-like growth, 
looking as much like a small sun-flower as anything 
to which I can compare it. It extended for an inch 
about the anus on each side, and somewhat farther 
back towards the coccyx than forward on the peri- 
neum. In places the growth was ulcerated, bleeding 
somewhat easily upon touching. It extended poste- 
riorly about two inches up the rectum, its boundary 5 
being well defined. The examination, made without 
giving an anaesthetic, gave her much pain. 
Her menstrual periods were normal, and, as she ex- 
pected her monthly sickness in two or three days, an 
operation was advised to be done as soon as she was 
well over it. This was readily assented to by herself 
and husband, her words being: “I cannot live long 
in this condition.” She was given quinine quite 
promptly, and her rectum washed out each day by an 
injection of tepid water. Two doses of castor oil 
were also given. Oct. 1st, her menstruation having 
ceased two days previously, assisted by Drs. Snow, 
Perry, and my medical student, Mr. Worden, I pro- 
ceeded to do the operation of excision of the rectum. 
Ether was given by Dr. Perry, and the patient was 
placed in the position for lithotomy. With the scal- 
pel I made an elliptical incision, beginning in front 
of the anus, and then around on each side backward 
to the coccyx. With serrated scissors I continued 
the dissection, keeping my finger well in the vagina 
to protect, as much as possible, the recto-vaginal sep- 
tum. The bleeding vessels were controlled by the 
use of Wells’s artery clamp, and the time occupied in 
completing the removal of the diseased mass was 
about fifteen minutes. Ligatures were applied to 
eight bleeding arteries. 
On careful examination, it was found we had re- 
moved more than two inches of the rectum posteriorly 
and only about an inch in front—in fact, at the latter 
point, there was evidently a part of the external 
sphincter muscle left, but the disease was believed to 
be thoroughly removed. The rectum was now brought 
down, and by ten stitches attached to the cutaneous 
surface. After this the oozing of venous blood en- 
tirely ceased. Cloths dipped in a weak solution of 6 
carbolic acid were applied, and the patient placed in 
bed. The shock was somewhat marked, the opera- 
tion having lasted nearly an hour. She rallied from 
the effects of the ether quite rapidly. Her urine was 
drawn in the evening by catheter, and by the aid of 
-§• gr. morphine she passed a comfortable night. 
Temperature 6 p.m., 101 ; pulse, 108. The next day 
after the operation she expressed herself as feeling 
very comfortable, none of the old pain or irritation 
remaining. This patient made such an uninterrupted 
and successful recovery, that it is hardly necessary to 
give her daily record. Her temperature was never 
above 102, and that was for one day only. One 
point of interest in the case was, that all the stitches 
gave way between the third and fourth day. The 
ligitures were all away by the eighth day, the suppu- 
ration being quite free. The parts, however, wrere 
kept in good condition by frequent washing with 
carbolized water. No tendency to burrowing of pus. 
The quinine was continued for two weeks. On the 
tenth day, the bowels were moved by castor oil and 
injections, giving her considerable pain and causing 
some bleeding. The catheter was not used after the 
second day. At the end of the second week after the 
operation, the patient was put upon a mixture of 
liquor pernitrate of iron and Fowler’s solution, and 
this was continued for eight months, when her color 
and general appearance were that of perfect health. 
Siuce the healing of the parts, she has had more or 
less trouble in getting her bowels to move. There 
has been very little tendency to diarrhoea, but the 
contraction about the anus is very decided, so that, in 
the three examinations 1 have since made, I could 
hardly introduce my little finger without giving pain 
to the patient. 7 
At first, to relieve the constipation, I gave the 
patient Lady Webster dinner pills, and advised the 
daily use of the rectal bougie. The former, however, 
seemed to give griping pain, or, as she expressed it, 
“too urgent a desire for an evacuation,” while the 
latter was too troublesome to use for any length of 
time. For the past six months she has succeeded 
nicely in moving her bowels by the use of an enema. 
At the present time, May 1, 1879, she seems in ex- 
cellent health, and is free from all pain or irritation 
about the parts. Microscopic examination of the 
growth at the time of its removal showed it to be a 
papilliform form of carcinoma. 
Case II.—Epithelioma of rectum—Three inches re- 
moved.—In Feb., 1878, my friend Dr. Roscoe, of Car- 
lisle, N. Y., brought to my office Mr. Wm. Becker, to 
be examined in reference to the condition of his rec- 
tum. Mr. B. gave the following history: He was a 
farmer, aged 58, married, and has three children, all 
grown and in good health. About nine years ago he 
first noticed his trouble, which he believed to be piles. 
He was treated by external applications, at times 
being worse, and then better, until three years since, 
when he had an abscess, which discharged quite 
freely. From that time the itching, irritation, and 
moisture of the parts have increased, being accom- 
panied by sharp, lancinating pains ; also at times by 
violent burning pains, which the patient very vividly 
describes. At times he would be troubled by diar- 
rhoea; his pain, however seemed greater when the 
bowels were constipated. He frequently experienced 
also a sensation, caused apparently by the presence 
of something in the lower bowel, he felt 
he must force out. 
On examining the parts, I found, just within the 8 
muco-cutaneous border, an ulcerated mass extending 
up on the right side as far as my finger could reach. 
The glands in the inguinal region, however, as well 
as the bladder and prostate, seemed in a healthy con- 
dition. He presented a somewhat cachectic appear- 
ance, loss of appetite, emaciation, etc. I advised an 
operation for the removal of the lowTer portion of the 
bowel, to which he readily consented. Accordingly, 
at his home, March 8, 1878, assisted by Drs. Roscoe, 
Perry, and Lowell, I did about the same operation as 
in Case I. 
Having the catheter in the bladder, I made a com- 
plete dissection and removal of the rectum, to the ex- 
tent of three inches on the right side and about two 
on the left. I did not, however, as in the preceding 
case, attempt to stitch the bowel to the skin; but, 
after securing the vessels, which were quite numerous, 
I placed a drainage-tube in the wound, applied a pad 
of absorbent cotton', and held all in place by a T- 
bandage. The cotton was removed on the second 
day, after which the wound was kept clean by tbe 
use of carbolized water. He made a good recovery, 
the ligatures being allowed to come away of them- 
selves. Since last May he has had very good control 
of his bowels, though wThen the desire comes to go to 
stool he must respond at once, or there will be a par- 
tially involuntary escape of faeces. He has improved 
very much in health, and is free from all pain and 
irritation. 
March 3, 1879.—Dr. Roscoe visited my office, and 
stated that, during the previous month, Mr. B. had 
noticed an enlargement in his left groin, which was 
hard and somewhat painful, but free from adhesions. 
This looks like a return of the disease, though in 
every other respect he seems well. 9 
This patient took, for a long time after the opera- 
tion, the mixture of pernitrate of iron and Fowler’s 
solution, with seemingly good effect. 
May 1, 1879. Mr. B. seems in excellent health, 
and is worried only by the indurated superficial in- 
guinal gland in the left groin. About the rectum 
the parts present a healthy appearance. 
I have reported these two cases, the only ones in 
which I have operated, not so much on account of 
their success, as the desire I have to add to the sta- 
tistics of the operation, believing that time will dem- 
onstrate that it lies in the power of surgery to do 
more for these unfortunate patients than has hitherto 
been thought possible by many good and wise sur- 
geons. 
At the present time, while there are many favorable 
cases reported, yet the operation is considered as a 
palliative one merely. The period of immunity after 
operation cannot be determined. The conditions 
which seem to justify the operation, and which are 
emphasized in many of our late works on surgery, 
were well exhibited in my two cases—namely, the 
disease being epithelial in its character, limited to 
the walls of the intestines, not implicating the perito- 
neum, and the health of the patient not too seriously 
impaired. The fact that the greatest amount of the 
disease was situated toward the coccyx, made these 
two cases exceptionally favorable for the operation. 
I desire to call attention to the excellent use that can 
be made of the curved serrated scissors in doing this 
operation. It seems to me the immediate bleeding is 
not near so great, and that a good deal of the usual 
sponging is avoided. 
I think there is much yet to be considered regard- 
ing the use of sutures. The principal causes of death 10 
in this operation have been pyaemia, pelvic cellulitis, 
and peritonitis. With this knowledge in our posses- 
sion, is it not safe to do away entirely with sutures, 
give free exit to the wound by the aid of drainage- 
tube and frequent washing out, keeping the parts in 
an antiseptic condition, and avoid the possible danger 
there is in the sutures, closing the parts in such a 
manner as to cause the pus to be retained, and thus 
most certainly produce some of the results that are 
known to prove fatal? I should like a fair, candid 
expression from the surgeons who have done this 
operation, as to how much service the sutures have 
been in holding the rectum down to the cutaneous 
surface, and whether if, in the majority of cases, they 
have not torn out before primary union could possibly 
occur.