A CONTRIBUTION TO THE STUDY OF 
CANCER OF THE RECTUM 
BY 
LEWIS A. STIMSON, M. D. 
SURGEON TO THE PRESBYTERIAN AND BELLEVUE HOSPITALS J PROFESSOR 
OF PATHOLOGICAL ANATOMY IN THE UNIVERSITY OF THE 
CITY OF NEW YORK 
[reprinted from “archives of medicine,’’augugt, 1879.] 
NEW YORK 
G. r. PUTNAM’S SONS 
182 FIFTH AVENUE 
1879 A CONTRIBUTION TO THE STUDY OF CANCER OF 
THE RECTUM, 
By LEWIS A. STIMSON, M. D., 
SURGEON TO THE PRESBYTERIAN HOSPITAL. 
IN the number for March 13, 1878, of his Klinische Vor- 
trcigc, Volkmann published an article upon extirpation 
of the rectum for cancer, which was noticed in many jour- 
nals and received much attention. The author claimed 
that the thorough removal of the cancerous tissue would 
effect a complete cure, or would at least be followed by a 
return of the disease only after the lapse of a long period, 
six or eight years in some cases, and also that the use of 
antiseptic precautions made this thorough removal a com- 
paratively safe operation even when carried to the extent 
of opening the peritoneal cavity in the wound. His record 
of results bore out his statements, and his cases were so 
numerous that the reader might easily receive the impres- 
sion that the author had operated upon most of the cases 
that presented themselves, and overlook the briefly stated 
opinion near the end of the paper, that it is comparatively 
seldom that an operation is justifiable. 
In July, 1878, Prof. Van Buren published the notes of 
four cases in which he had advised removal by Volkmann’s 2 
LEWIS A. S TIM SON. 
method, in the N. V. Medical Record, “ as a contribution 
towards the better knowledge of the proceeding, simply as 
regards its feasibility and safety ; for its value as a remedy 
we must await results.” Since this publication four ad- 
ditional operations in three new cases and in one of the old 
ones have come under my observation, which, with the 
subsequent history of the others and the microscopical ex- 
amination of the specimens, throw some light upon the 
natural history of the disease and upon the facts which 
must determine the propriety of interfering actively, and 
the choice of an operation. 
Removal of a cancer of the rectum is by no means a new 
operation, but, as heretofore practiced, it has proved a 
dangerous one, even when the tumor was small. The 
records of the operation show that the fatal issue is most 
frequently due to a diffuse, rapidly advancing septic inflam- 
mation of the para-rectal and retro-peritoneal connective 
tissue, extending sometimes in a few hours even to the dia- 
phragm, and frequently associated with septic peritonitis. 
Volkmann sought to meet this danger, which seemed to 
have its origin in the retention and decomposition of the 
secretions, by thorough drainage through side channels 
established for the purpose, and by the use of not only the 
ordinary antiseptic measures but also that of antiseptic irri- 
gation maintained for several days after the operation. 
The success that has attended these measures proves it 
to be safe and possible, he claims, to remove the diseased 
parts much more thoroughly than has heretofore been at- 
tempted, and this thoroughness of removal has the great 
advantage of delaying the return of the disease and even in 
some cases of effecting a permanent cure. The extent to 
which he safely carried this removal is far in advance of 
anything that was done under the earlier methods, both in 
the length of the portion of the rectum and in the amount CANCER OF THE RECTUM. 
3 
of infiltrated connective tissue removed. The peritoneum 
even was opened in eight cases, all of which recovered. 
The importance of any method that allows of the safe 
and thorough removal of cancerous portions of the rectum 
is relatively increased by the limited range and unsatisfac- 
tory character of the therapeutical alternatives, which, leav- 
ing a radical cure entirely aside, go no further than the 
establishment of an artificial anus in the hope of retarding 
the growth of the tumor and diminishing the pain, or may 
even be limited to keeping open a passage by scraping 
away the obstructing nodules and granulations or by the 
frequently repeated painful use of bougies. It has been 
amply shown that removal may, under certain circum- 
stances, be followed by a permanent arrest of the disease, 
or at least by a period of freedom from any of its mani- 
festations sufficiently prolonged to justify the interference. 
But it is equally certain that in other cases the progress of 
the disease has been rendered only more rapid by the inter- 
ference, and that the relief from pain, the only advantage 
derived by the patient from the operation, might have been 
obtained more easily and effectually in some other manner. 
The important point therefore, the one to which our in- 
vestigations should now be directed, is to learn to distin- 
guish between tumors that are suitable for removal and 
those which are not. Operative surgery has provided for 
the proper treatment of both varieties ; we can safely and 
effectually remove the former, and by opening the colon in 
the groin or in the loin we can meet the symptomatic indi- 
cations of the latter ; it remains to know when to attempt 
a cure, and when to stop at alleviation. 
It is natural in seeking the answer to this question, to 
turn first to the anatomical structure of the tumors, and see 
if there are any histological differences which correspond 
with, even if they do not explain, the differences in prog- 4 
LEWIS A. S TIM SON. 
nosis. It is only too often the case that this line of investi- 
gation leads to results that have but a limited practical 
bearing because of the difficulty of applying them to a 
given case at that period in its treatment when the appli- 
cation can alone be of use. Their greatest value is to be 
found in the means they afford of classifying clinical facts 
in such manner that more positive conclusions can be early 
drawn from them, and in bringing to light the natural 
history and tendency of the morbid growths. Clinicians 
and histologists have found in the rectum most of the varie- 
ties of tumors found elsewhere in the body, and there is no 
good reason for calling in question the accuracy of their ex- 
aminations and descriptions, although it may be doubted if 
many of the varieties do not differ from one another rather 
in degree or mode of development than in their essen- 
tial nature. With perhaps one exception, the morbid growths 
in the cases here considered belong in the class to which 
the name of cylindrical-celled epithelioma is given. The 
possible exception belongs to the variety known as colloid 
cancer, and although my examination was less thorough 
than I could have wished, I believe its origin to have been 
the same as that of the others. Some of the tumors showed 
individually at different points appearances which have been 
described as characteristic of radical differences in structure 
and nature; and, taken altogether, they present a complete 
series of gradations between what is described as polyp on 
the one hand and scirrhus or true carcinoma on the other. 
The enlarged and lengthened tubules of the mucous mem- 
brane, growing outwards into the lumen of the bowel, and 
showing no tendency to invade the underlying tissues, are 
found side by side with other similar tubules extending 
downwards into and through the muscular tunic, and reap- 
pearing in typical form in distant lymphatic glands. And 
in the deeper parts these tubes and their epithelial lining CANCER OF THE RECTUM. 
5 
undergo a series of changes in size, arrangement and shape 
(Figs. 2, 3, 4, 7, 11), which ends in the production of a tissue 
composed of small alveoli filled with irregularly globular 
epithelial cells and separated from each other by a fibrous 
stroma, a tissue having the appearance of true carcinoma. 
There is no fundamental difference in the anatomical 
elements of these tumors to explain the difference in the 
results of the operations, but the tendency to local return 
seems to have depended entirely upon the extent to which 
the disease had involved the muscular coat of the intestine 
and the adjoining tissues. Only five of the eight cases here 
mentioned bear directly upon the question of return, for 
the remaining three died in consequence of the first opera- 
tion upon them. The disease returned locally in three of 
these cases; the other two have remained free from it for 
periods of nine and thirteen months respectively. In all 
five cases the prominent anatomical characteristic of the 
tumors was the presence of tubules of irregular size and 
shape, lined with cylindrical epithelium. In the two suc- 
cessful cases the morbid tissue did not extend through the 
underlying thickened muscular coat of the intestine; even 
at the central, thickest part it was still distinctly limited by 
a layer of unstriped muscle. In the other three cases, on 
the contrary, the muscular coat was broken through, either 
largely or by a sort of perforation along the line of the 
blood-vessels; the adjoining connective tissue was con- 
densed and hardened, and the lymphatic glands wrere en- 
larged and contained typical cylindrical epithelial forma- 
tions. This implication of the para-rectal connective tissue 
and glands was noticeable not only in these three cases, but 
especially so in the cases in which the operation had a 
promptly fatal result. In these latter, and in one of the 
others (Case V), it was so extensive that a complete re- 
moval of the affected tissue was impossible, and it rendered 6 
LEWIS A. STIMSON. 
it difficult to bring down the upper end of the rectum suffi- 
ciently to attach it to the margin of the external incision 
without undue tension. 
The three cases (Cases I, II, V) showed very plainly the 
part taken by the connective tissue, or the lymphatic glands, 
in the local return of the disease. In two of them (Cases 
I and II) the disease was found to have returned, on exam- 
ination about seven months after the operation, in glands 
lying outside of and adherent to the rectum. In Case I the 
gland was removed through an incision made along the side 
of the coccyx and sacrum, and showed on examination 
tubules lined with cylindrical epithelium. A second return 
occurred in this case a few months afterwards. In Case V 
the stitches uniting the upper end of the rectum to the 
skin tore out and the gut retracted, leaving an annular raw 
surface from three to five centimetres in breadth to heal 
by granulation. A month after the operation, firm, hard 
nodules were found scattered over this surface, and these 
nodules which, although not examined microscopically, 
were undoubtedly cancerous, increased until their mass 
almost completely filled the excavation. 
The mucous membrane limiting these tumors exhibits 
changes which clearly show their mode of lateral growth or 
extension (Fig. io.) The tubes at an average distance of 
perhaps five millimetres from the edge of the tumor begin 
to lengthen and increase in diameter. Their epithelium 
shares to a variable degree in this hypertrophy, and some- 
times the cells are distended by a clear, highly refracting, 
mucus-like substance. This enlargement increases steadily 
as the edge of the tumor is approached, and young em- 
bryonal cells are found in increasing numbers in the corre- 
sponding portion of the submucous layer of connective 
tissue. The thin layer of unstriped muscle lying between 
the tubes and the submucous connective tissue, the muscu- CANCER OF THE RECTUM. 
7 
laris mucosae, persists apparently unchanged to the edge of 
the tumor; and at the point where it disappears the hyper- 
trophied tubes take a sudden extension downwards into 
the thickened underlying layer of soft, young, embryonal 
cells, become irregular and branched, and their epithelium 
small and dark, with a tendency to become more globular 
and less cylindrical. 
The normally scanty connective tissue between the tubes 
shares in the general hyperplasia, and merges with that of 
the submucous layer. When the surface ulcerates this 
tissue undertakes as usual the work of repair, and produces 
masses of granulations, in which the epithelial formations 
are found scattered at irregular intervals. 
Under some unknown conditions the muscularis mucosae 
persists, becomes thickened, and is reinforced by the devel- 
opment into fully formed connective tissue of the em- 
bryonal cells of the submucous layer. The overgrowth of 
the. mucous membrane, and the retraction of the submucous 
layer, like that of a cicatrix, throw' the former into a fold 
(Fig. i), or, if only a restricted area is thus involved, into a 
polyp. This tendency to the formation of a projecting 
ridge or fold, is, of course, most marked at the border of 
the tumor, and is strengthened by inflammatory thickening 
of the para-rectal connective tissue, which, by preventing 
distention of the bowel, and maintaining its normal folds, 
favors the retention by the morbid growth of the normal 
form of the parts. 
It is not uncommon also to find the morbid tissue extend- 
ing laterally at some points on the margin along the sub- 
mucous layer, under the unbroken muscularis mucosae. 
Such points appear as firm rounded ridges covered with 
mucous membrane which to the touch and eye appears un- 
altered, .except in being rather more coarsely velvety than 
is natural. The section of these ridges shows very plainly 8 
LEWIS A. ST IM SON. 
a thickened mucosa resting upon an opaque white or yellow- 
ish mass, which itself lies upon, or is superficial to, the 
muscular tunic, and is continuous with the main body of 
the tumor, and identical with it in structure. This exten- 
sion laterally along the submucous layer is in accordance 
with the well-known tendency of morbid epithelial growths 
to spread into softened proliferating connective tissue, or 
along what may be considered lines of least resistance. 
The muscular coat of the intestine dips downward at the 
margin of the tumor, and extends under it in an unbroken 
line in the earlier or less developed stages of the affection. 
In the later stages its continuity is broken, and its identity 
as a layer lost, by union with the thickened para-rectal tissue 
and infiltration by the epithelial formations. It is always 
thickened by increase of its muscular and connective tissue 
elements. In some cases the muscular fibres are separated 
into small bundles by wavy bands of fibrillary tissue ; in 
other cases the routes of the perforating vessels are marked 
by rapid and abundant proliferation of the cells of the 
accompanying connective tissue, a proliferation which pre- 
pares the way for the spread of the epithelial growths in 
the same direction. 
The condition of the para-rectal connective tissue de- 
pends upon the depth to which the tumor has penetrated, 
and upon its extension laterally around the interior of the 
bowel. If the muscular tunic is unbroken, the thickening 
of the outer connective tissue is mainly confined to an area 
corresponding sensibly to the central or thickest part of the 
tumor, and it seems to be due entirely to a chronic inflam- 
matory process set up and maintained by the adjoining mor- 
bid change, and not to specific infection or infiltration. If, 
on the other hand, the muscular coat is broken, the adjoin- 
ing tissue furnishes a favorable nidus for the spread of the 
disease; it thickens rapidly in all directions, and the lym- CANCER OF THE RECTUM. 
9 
phatic glands imbedded in it enlarge, harden, and become 
the seat of secondary epithelial deposits (Fig. 7). It is not 
probable that this infection is delayed until after the mus- 
cular tunic has been plainly broken through ; the process is 
more likely to be a gradual and contemporaneous one, the 
infection and the perforation taking place along the line of 
the vessels as above described ; but it is certainly slow in 
the beginning, and takes its first rapid strides outside along 
the lines of the lymphatics only after the muscular barrier 
has been effectually broken down. The corresponding re- 
sistance to the spread of the affection offered by the thin- 
ner and weaker muscularis mucosae has already been men- 
tioned. 
In examining the masses removed by operation, I have 
found enlarged and diseased glands at a distance of more 
than 5 cm. from the point at which the muscular coat had 
been perforated. In all such cases which survived the 
operation, the disease, as I have already stated, recurred 
locally, and there is no reason to think that removal suf- 
ficiently complete to effect a permanent cure is practicable 
when the disease has progressed to such an extent. 
When the tumor involves a more or less annular segment 
of the bowel, and presents a notable obstacle to the pas- 
sage of the faeces, the thickening of the para-rectal tissues 
is increased by the mechanical violence inflicted upon the 
parts, and by the forcing downwards of the narrowed seg- 
ment during the act of defecation. The use of bougies to 
enlarge the opening probably has the same effect, because 
dilation can be effected only by the rupture or stretching of 
the rigid fibres whose natural (cicatricial) retraction has been 
the cause of the narrowing. Each such act of violence ex- 
cites a fresh proliferation, and thus hastens the progress of 
the disease. 
The clinical history of this affection is not as complete as 10 
LEWIS A. S TIM SON. 
could be desired, because an opportunity to observe its be- 
ginning is seldom given. In two of the cases here recorded 
{Cases III and VII), the patients came under observation 
at an early period. In each case the medical attendant de- 
tected a polyp which had given rise to' some bleeding, and 
removed it more or less completely. A second examina- 
tion in each case, after the lapse of about eighteen months, 
disclosed an unmistakable epithelioma. In Case I there was 
a history of “ulcerated haemorrhoids,” which had been fre- 
quently cauterized and snipped off. In all the others the 
tumor was found on the first examination, and the ante- 
cedent history was only that of more or less obscure rectal 
trouble and bloody stools. 
The fully-developed tumors were found on digital ex- 
amination to be hard lumpy or tuberculated masses, ulcer- 
ated at one or more points, sometimes with elevated well- 
defined borders, and sometimes shading off as a granular or 
•coarsely velvety mucosa. Usually they surrounded the 
bowel entirely, or nearly so, and appeared in all cases to 
have begun upon its posterior surface. The tumor was, in 
some cases, continuous with the anus ; in others, separated 
from it by a strip of mucous membrane of varying width. 
In every case the upper margin of the tumor was within 
reach of the finger. The ulcerated surface was elevated 
and covered with granulations, except in Case VIII, where 
it was deeply excavated. The ages of the patients were 30, 
33, 36, 40, 42, 50, 50, and 64 years. In the youngest and 
the oldest, treatment was most successful. Four were males, 
four females. 
The extent of para-rectal thickening is not easily esti- 
mated by the finger, and mobility of the tumor is not a 
trustworthy indication, because it may coexist with an 
amount of thickening and infiltration which renders com- 
plete removal impracticable. The duration of the affection CANCER OF THE RECTUM. 
11 
also throws no light upon this point, because the date of its 
beginning can seldom be determined. In the two cases in 
which the disease began as a polyp, the period between the 
recognition of the polyp and that of the fully-developed 
tumor was about eighteen months. It is evident, however, 
from the results of the microscopical examination given 
above, that the determination of the amount of thickening 
is vital to the question of treatment, because it is a measure 
of the extent of lymphatic infiltration or infection, and, 
of the probability of local return or generalization. 
If the record of these cases is examined with reference 
to this point, it appears that the para-rectal tissue was ex- 
tensively involved whenever the calibre of the rectum was 
so narrowed circularly as to offer a distinct obstacle to de- 
fecation. In the only case of this kind which survived the 
operation (Case V), the disease returned locally before the 
the wound had healed. In another case (Case II), where 
there was circular implication of the bowel, but no note- 
worthy narrowing, a large hard lump, not adherent to the 
mucous membrane, was distinctly felt and included in the 
ligatures by which the affected zone was removed. The 
disease returned immediately in the cicatrix, and when a 
second removal was made by the knife, six weeks after the 
first, the connective tissue and some lymphatic glands were 
distinctly involved, as the microscope proved. In the two 
cases in which the disease has not recurred (Cases III and 
VII), it existed as one or more elevated patches with a 
granulating surface ; the elevation of the patch in Case VII 
was such as to almost give it the appearance of a sessile 
growth. 
These facts seem to establish two extremes: 1st, that 
narrowing of the bowel sufficient to be a distinct obstacle 
to the passage of the fmces is accompanied by implication 
of the deeper tissues to an extent which renders prompt 12 
LEWIS A. STIMSON. 
local return of the disease certain ; and 2d, that when the 
disease exists as a circumscribed raised patch with an 
exuberantly granulating surface its removal may effect a 
radical cure. Between these two extremes there must 
exist a series of gradations, in the great majority of which, 
however, the disease will return ultimately, the differences 
lying in the activity of the recidive and the length of the 
period during which the patient will remain free from it. 
Return after free removal occurs first in the para-rectal con- 
nective tissue and involves the bowel only secondarily, in 
Case II only after the formation of abscesses which burst 
into the rectum. 
If now upon these anatomical and clinical data we at- 
tempt to construct a theory of the character and develop- 
ment of the disease, we must regard it as one which, begin- 
ning as a simple local affection of the mucous membrane, 
progressively involves the underlying tissues, and ends in 
generalization through the lymphatic system. The fact 
that most of the tumors apparently began upon the posterior 
wall of the rectum about two inches above the anus makes 
a local constant cause probable, and points to some action 
upon the mucous membrane by the faeces, a mechanical ac- 
tion due to their arrest and pressure there, aided perhaps 
by some irritant change in their constitution. 
It does not lie within the proposed scope of this paper to 
discuss the question whether cancer is primarily a local or 
a constitutional affection. The explanation of the local ap- 
pearance of the disease and of its local return after removal, 
given by Sir James Paget, who is perhaps the most promi- 
nent upholder of the constitutional theory, is so far in 
accord with that offered by those who hold to the local 
theory as to render the discussion, in my judgment, mainly 
one of terms and definitions. If it is admitted that cancer 
of the rectum is essentially a glandular or epithelial affec- CANCER OF THE RECTUM. 
13 
tion, one having its origin in the mucous membrane, the 
borders of the growth, as being the freshest, most recent 
portions, must be examined, as in carcinoma of other 
organs, for evidences of primary changes and mode of de- 
velopment. These changes have been already described. 
They consist of hypertrophy of the mucosa by hypertrophy 
and hyperplasia of its epithelial elements, together with an 
abundant development of embryonal connective tissue be- 
tween the tubules. They are the same as those found in a 
variety of neoplasm of recognized benign character known 
as polyp of the rectum or polypoid adenoma. The forma- 
tion of a pedunculated growth with a tendency to isolation 
in the one case, and of a flat growth with a tendency to 
spread laterally and into the underlying tissues in the other, 
may be explained partly by mechanical causes and partly 
by the degree of intensity of the changes in the submucous 
connective tissue. If the primary change occupies a limited 
area upon a natural fold of the mucous membrane, and if 
the muscularis mucosae remains unbroken until the young 
embryonal cells produced below it, in consequence of the 
neighboring irritation, have had time to develop into adult 
fibrous tissue, the natural retraction of this new tissue nar- 
rows the base of the fold, giving it at once a polypoid form 
and opposing by its greater density a stronger barrier to the 
extension of the epithelial formation in this direction. The 
pedicle once formed, the neoplasm increases in the direc- 
tions open to it, that is, into the lumen of the canal in all 
its diameters, and the dragging to which it is subjected by 
the constantly recurring passage of the faeces lengthens its 
pedicle and tends towards its final separation. 
On the other hand if a broader area is occupied by the 
primary change, or if the processes are more intense and 
rapid, the pedunculation is absent or less perfect, and the 
epithelial growths of the mucosa break through immediate^ 14 
LEWIS A. S TIM SON. 
or after an interval spent in overcoming the greater resist- 
ance offered by the partial pedunculation, into the sub- 
mucous tissue. Once established in that region the spread 
of the disease is easy, and its ultimate generalization a 
question only of time. 
The second and final barrier to generalization is presented 
by the muscular coat of the intestine, but it is a barrier in 
which are many gaps, large ones along the lines of the ves- 
sels, and innumerable small ones in the fine meshes of con- 
nective tissue which separate the muscular bundles and are 
continuous with the submucous tissue on one side and the 
para-rectal tissue on the other. Here, too, the intensity of 
the process materially affects the rapidity of its extension, 
for if the proliferating connective tissue, which is most 
easily implicated while it is in the formative stage, is al- 
lowed time to reach its full development, to become fibrous, 
it forms, as it were, a second line of defense capable of 
offering a certain resistance after the first line has been 
carried. 
In the relative predominance of the production of con- 
nective tissue over that of the epithelial formations which 
are imbedded in it, lies the explanation of a fact observed 
in the two successful cases here recorded (Cases III and 
VII), and perhaps also of their less degree of malignancy. 
In both cases the ulcerated surface was covered with exu- 
berant granulations containing very few tubules, and form- 
ing masses or lumps which in one case were broken off in 
considerable quantities during the operation. The predom- 
inance of granulation tissue in these detached pieces was so 
great that repeated examinations of some of them failed to 
show any tubules. The surface from which they came was 
very vascular, the vessels consisting of large, thin-walled, 
freely-inosculating, thickly placed capillaries. In a word, 
the surface was that of an ordinary granulating ulcer, and CANCER OF THE RECTUM. 
15 
the granulations had their origin in the stroma of the 
tumor. It seems reasonable to suppose that this tendency 
to more vigorous production of connective tissue, as com- 
pared with the epithelial elements, near the surface, existed 
also in the deeper parts, and aided in the manner above de- 
scribed to delay the cancerous implication of the para-rectal 
tissue. 
I have used the terms cancer and cancerous in speaking of 
these tumors and different processes observed in them, be- 
cause I believe them to belong to a connected series of 
morbid changes, the ultimate term of which presents char- 
acteristics, anatomical and clinical, the idea of which is 
generally accepted as attaching to .those terms. Even if 
this belief should be erroneous, the error would not, I think, 
affect the following clinical deductions. 
Treatment.—In estimating the advantages of treatment, 
the probable comfort of the patient and the period of his 
survival in case of non-interference, must be taken into 
account. The present cases afford no positive data upon 
the latter point, but the degree of cachexia, of functional 
disturbance, and of pain in all except Case II, was such that 
a prolongation of life for twelve months after they first 
came under observation was improbable. In another case, 
not included in this paper, which came under my care about 
three months ago, and was not considered suitable for oper- 
ation, the patient, himself a physician, first noticed the 
symptoms of the disease in August, 1878, and he died in 
May, 1879. 
Comparing this prognosis with the results of active inter- 
ference, we find that in four cases death followed within 
ten days after, and as the result of, the operation. In one 
of these cases a chill, supposed at the time to be malarial,, 
but which was possibly pyacmic, occurred the day before 
the operation. In two others the patients’ general condi- 16 
LEWIS A. STIMSON. 
tion was very bad, and the disease very extensive. In the 
remaining case the patient had previously undergone two 
operations, the first twenty months, the second ten months 
before, and was much exhausted by pain and suppuration. 
Of the seven survivals after operation (representing five 
patients) two patients have remained entirely well and free 
from any return of the disease for thirteen and nine months 
respectively, and one patient died six months afterwards in 
consequence of prompt local return and rapid progress of 
the disease. One patient (Case II) underwent a second 
operation two months after the first, and on examination 
eight months afterwards the disease was found to have re- 
turned again; during the six months that have elapsed 
since that examination, it has progressed rapidly, and an- 
other attempt at removal is not considered justifiable. 
The remaining patient (Case I), improved greatly in health 
after his first operation. His second operation was per- 
formed a year after the first, and consisted in the removal 
of an affected lymphatic gland by an incision not involving 
the anus or rectum. His third operation was performed 
ten months after the second, and is included above among 
the fatal ones. 
The Lister method was employed in five of the eleven 
operations; one of these (Case VI) died of peritonitis. 
Carbolic acid, without the spray, was used freely in three 
cases (I, IV and VIII); all died, one of pyaemia, one of ex- 
haustion, and the third of exhaustion, after passing through 
.an attack of peritonitis. 
Removal of the entire cylinder, including the anus (the latter 
being a precaution recommended by Volkmann to diminish 
the chances of return), was done in five cases (I, III, IV, V 
and VI). One has remained well, one had local return of 
the disease, three died of the operation. 
Removal of the entire cylinder, not including the anus, was CANCER OF THE RECTUM. 
17 
done three times in two cases (II and VIII), twice by the 
knife, once by ligature. In the latter case the disease re- 
turned immediately, before the wound had healed; one 
died of the operation, and in the other the disease returned 
in eight months. 
Removal of only the affected portion, not including the 
entire circumference of the bowel, was done in two cases (I, 
VII). In one (removal by the £craseur) local return was 
detected in seven months; the other has remained well for 
nine months, as has been proved by several examinations. 
These cases are too few and too varied in their treatment 
to allow of any very positive formulation of therapeutical 
principles upon them, nor is that the object of this paper, 
which is intended rather as a simple contribution to the 
study of the subject. Nevertheless, a few conclusions may 
be fairly drawn. 
The first one is, that Volkmann’s enthusiastic presenta- 
tion of the advantages of extirpation of the rectum under 
antiseptic precautions is calculated to mislead surgeons, by 
inducing them to undertake it under circumstances which 
ought to clearly contra-indicate it. For, while the use of 
carbolic acid and drainage has notably lessened the dangers 
of the operation, it is far from guaranteeing patients, 
especially the feeble and cachectic, from death by shock, 
peritonitis, or exhaustion ; and when the infiltration of the 
para-rectal tissues is extensive, one of two things will prob- 
ably happen : either the patients will have become so re- 
duced by functional disturbances, and the establishment of 
a constitutional infection, that they will be unable to meet 
the demands of the process of repair; or, secondly, the 
upper segment of the bowel will have become so adherent 
to the sacrum that it cannot be brought down to complete 
the operation properly by stitching it to the skin or lower 
segment, and the disease will return promptly in the wound. 18 
LEWIS A. STIMSON. 
When the disease involves the bowel circularly, and has 
been the cause of difficult and painful defecation for several 
months, and if the ulcerated surface is excavated, it may be 
considered certain that the connective tissue and glands are 
extensively involved. Under such circumstances, an attempt 
to remove the tumor radically must be unsuccessful, and if 
any operation is called for it should be a palliative one, such 
as the establishment of an artificial anus in the groin or 
loin. 
On the other hand, tumors involving only a portion of 
the circumference of the bowel, with raised, well-defined 
borders, and a flat or lumpy, broadly-ulcerated, easily-bleed- 
ing surface, are slow to implicate the para-rectal tissue, and 
are, therefore, the most favorable cases for radical cure by 
removal. 
Between these two extremes lie the cases in which, while 
it is probable the patient will recover from a well-conducted 
operation, it is certain that if he should do so, the disease 
will return in a few months in the tissues outside the rec- 
tum. The relief of the patient during this period is so 
complete, and the progress of the disease so far delayed, 
that it is justifiable to undertake the operation with the sole 
object of obtaining these two results. In the milder cases 
of this series, the operation holds out in addition the chance 
of an extirpation possibly so complete as to result in a 
radical cure; while in the severer cases the preferences of 
the patient, his mental condition, and his material surround- 
ings must be taken into account in determining whether to 
attempt extirpation or to be content with colotomy. 
Another deduction is, that not only is nothing to be 
gained by removing the anus when that is not involved, 
but also that is not even necessary to remove a circular seg- 
ment of the bowel when the tumor occupies only a portion 
of the circumference. A so-called “ partial ” removal can CANCER OF THE RECTUM. 
19 
be done as thoroughly as a “complete” removal, if division 
of the sphincter and bowel below the tumor is made the 
first step in the operation, and easy access to the under- 
lying tissues thereby obtained. And yet it must be remem- 
bered that the disability produced by removal of the sphinc- 
ter is not of much practical moment, and certainly not 
greater than that due to delayed and imperfect repair after 
its division. 
And, finally, remembering the insidious growth of the dis- 
ease, its amenability to treatment in its early stages, and its 
absolute lethality in the later ones, the physician should be 
always on the alert for the earliest indications of its pres- 
ence, and should not allow himself to be soothed into fan- 
cied security by the community between its symptoms and 
those of other and much less serious affections. A polyp 
or polypoid growth discovered in the rectum of an adult 
should be looked upon as a possible, the latter even as a 
probable, starting-point of carcinoma, and it should be im- 
mediately removed, and removed thoroughly. It may be 
proper to remove with the £craseur a polyp that has a long 
thin pedicle, but when the growth is at all sessile and hard, 
the only safe course is to remove by a formal operation all 
the tunics of the bowel with it. 
Methods of operation.—ist. In the operation of total 
extirpation, the rectum having been thoroughly emptied, 
an incision is made around the anus at a distance of one or 
two centimetres from its margin, and then extended poste- 
riorly in the median line towards the coccyx. By cutting 
with the knife or scissors, and tearing with the fingers, the 
surgeon makes his way upward outside the bowel, separat- 
ing it entirely from the adjacent tissues to a point some- 
what above the upper margin of the growth. If the rectum 
above this point is found so adherent that it cannot be 
easily brought down, its attachments must be still further 20 
LEWIS A. STEM SON. 
torn or cut until it is sufficiently liberated. All the lower 
portion, including the tumor, is then cut away, all thickened 
masses of connective tissue removed, and the edge of the 
bowel stitched fast to that of the skin. Drainage tubes are 
passed well up into the excavation on each side and behind, 
and brought out through the posterior incision, or through 
separate openings made in the skin for this purpose. It is 
well to place a rubber bag or ball in the rectum and inflate 
it so as to distend the rectum, and thus diminish the vacant 
space created around it by the dissection. Or, if the full 
Lister method is employed, a pouch of antiseptic gauze 
should be pressed up into the bowel and filled with plugs of 
the same material. 
2d. When a strip of healthy mucous membrane lies be- 
tween the tumor and the anus, and the latter is not to be 
removed, the sphincter should first be forcibly dilated, and 
then divided posteriorly in the median line towards or to 
the coccyx, and the incision prolonged up the bowel to the 
lower margin of the tumor. A corresponding incision may 
also be made anteriorly if absolutely required. The bowel 
is then divided transversely throughout its entire circumfer- 
ence below the tumor, and the operation proceeded with as 
in the former case, the end of the upper segment of the 
bowel being finally attached to that of the lower with silk 
sutures, and drainage entirely external to the rectum and 
anus provided for. 
3d. When the tumor involves only a portion of the circum- 
ference of the bowel, and a complete ring or cylinder is not 
to be removed, the operation is begun as in the second case, 
and then, starting from the upper end of the incision, the 
involved portion of the bowel is separated from the under- 
lying parts by tearing and cutting, and the incision is pro- 
longed around the tumor at the distance of one centimetre 
from it until it has been entirely encircled and removed. If CANCER OF THE RECTUM. 
21 
the gap left is a small one, its sides maybe sutured together 
longitudinally, but if it is a large one, the line of reunion 
should be crucial, the four corners at the crossing being 
held together by a stout silk ligature, embracing the entire 
thickness of the bowel. This ligature, like the others, may 
be left to cut itself out. Drainage must be as carefully pro- 
vided for in this case as in the others, and in the same 
manner. 
4th. Colotomy, as has been pointed out, may be employed 
as a palliative measure against pain, and also with advan- 
tage, I am inclined to believe, to retard the progress of the 
disease in case of its return in the tissues outside the bowel 
after extirpation. The operation in the left loin, lumbar 
colotomy, is now the method usually employed, but there 
are reasons why the other method, opening of the sigmoid 
flexure in the left groin, may be preferred, The latter 
method, which is generally known as Littr£’s operation, is 
free from some difficulties and chances of failure pertaining 
to the other, and the objection most strongly urged against 
it, that of having to open the peritoneum, has been shown 
by experience to be much less formidable than has been 
supposed. Its advantages are its ease of execution and the 
certainty with which the colon can be reached and opened. 
According to recent statistics, its mortality is not greater 
than that of lumbar colotomy. In lumbar colotomy the 
incision has to be carried through a much greater thickness 
of tissue, and the absence of landmarks is such that even 
surgeons of considerable experience in the operation have 
cut into the peritoneum accidentally, or have brought up 
and opened a loop of small intestine instead of the colon, 
and have discovered the mistake only at the autopsy. 22 
LEWIS A. ST IM SON. 
CASES.* 
Case i, under the care of Dr. Keyes. 
J. E.—, 50, a pale, thin, haggard man presented himself April, 
1877, with complaint of constant leakage of pus from the anus, 
and great pain, especially after stool when there is also blood. 
He gave a history of “ ulcerated haemorrhoids ” which had been 
frequently cauterized and snipped off. On examination a hard 
mass was felt about five centimetres above the anus, attached pos- 
teriorly, and involving from half to three quarters of the circum- 
ference of the rectum. The mass was slightly pedimentated and 
cauliflower-like ; it projected into the cavity of the bowel and in- 
volved the tissues between it and the sacrum, without being ad- 
herent to the latter. It was most bulky in the centre where it was 
ulcerated, and tapered off on both sides. 
1st operation, May 1. 1877.—The tumor was removed by first 
dividing it, the sphincter, and the skin back to the coccyx by means 
of the ecraseur, and then removing each half of the affected tis- 
sues by encircling them successively with the wire of the same in- 
strument. No antiseptics were used, the hemorrhage was slight. 
The growth was pronounced on microscopical examination to be 
a cylindrical-celled epithelioma. The patient made a good re- 
covery and went home in about six weeks. 
2d operation.—He returned six months afterwards considering 
himself cured, and reporting a gain of twenty pounds in weight. 
On examination a smooth hard lump as large as a walnut was felt 
just above the cicatrix, firmly adherent to the sacrum but entirely 
outside of and not involving the bowel. It was removed February, 
1878, through an incision made along the right side of the sacrum 
and coccyx without cutting into the bowel. The patient recovered 
rather slowly. 
T,d operation.—He returned to the city, December, 1878, thin 
and haggard, with constant dribbling of blood and mucus from 
the anus, and complaint of pain in the rectum and back. A cauli- 
flower-like growth occupied the cicatrix of the first operation and 
the bowel for some distance above it; the tissues between it and 
the sacrum were hard and infiltrated. Encouraged by his success 
in Cases II and III, Dr. Keyes determined to try complete extir- 
pation of the anus and cylinder of the rectum to the height occu- 
* Portions of the record of the first four cases were published by Ur. Van 
Buren, in the N. Y. Medical Record, July 13, 1878. CANCER OF TIIE RECTUM. 
23 
pied by the tumor, but he found himself unable to liberate and 
bring down the upper portion of the bowel or to remove all the 
infiltrated connective tissue, the upper limit of which was out of 
reach. He used carbolic acid freely to wash out the wound, but 
did not use the spray. The patient died of exhaustion within a 
week, no autopsy. 
The nodule removed at the second operation was composed of 
irregular tubules lined with cylindrical and irregular epithelium 
imbedded in a connective tissue stroma. 
The mass removed at the third operation shows an ulcerated 
surface about two centimetres in diameter, adjoining which on one 
side is a thickened fold one and a-half centimetres high and thick. 
The mucous membrane is velvety and injected. Vertical section 
through the fold shows a central stroma continuous with the mus- 
cular coat and lined by a manifold thickened mucous membrane 
shading off on the outer side to the slightly thickened mucous 
membrane of the adjoining surface, (Fig. 1). The surface of a ver- 
tical section through the ulcer is of an opaque, yellowish-white color, 
and of homogeneous appearance to the naked eye. Microscopical 
examination shows in the thickened mucosa of the fold irregular 
tubes lined with cylindrical epithelium ; and under the ulcer the 
same tubes modified in size, shape, and character of the lining cells 
as described more fully in Cases II, III and V. The tubes show 
the same tendency here to become smaller and lose their central 
cavity, their epithelium becoming at the same time more globular 
and less cylindrical ; and they are found side by side with groups 
of small alveoli occupied by irregularly globular epithelium, and 
separated from one another by a connective tissue stroma. (Fig. 2.) 
The strips of infiltrated para-rectal connective tissue show in 
places perfectly characteristic cylindrical-cell formations appar- 
ently not developed in lymphatic glands (Fig. 3.) ; and also some 
enlarged lymphatic glands presenting the same appearances. 
Case II, under the care of Drs. Van Buren and Keyes. 
Mrs. L.—, a large, well-nourished lady about 40 years old, pre- 
sented herself with a history of obscure pain or discomfort in the 
rectum which had been supposed to be due to malposition of the 
uterus. Examination of the rectum revealed a movable zone of 
lumpy thickening nearly surrounding the bowel at about five cen- 
timetres from the anus. This was removed March 10, 1878, by 
pinching it up in a transverse fold or tuck and transfixing the base 
of the fold with a continuous series of ligatures. The slough 24 
LEWIS A. STIMSON. 
came away in ten days and presented on examination the appear- 
ance of cylindrical-celled epithelioma, with a very abundant devel- 
opment of young connective tissue cells in a thick hard mass 
which underlay the zone at the posterior portion of the rectum. 
A month after the operation the wound was found cicatrized, ex- 
cept at one point on the posterior surface where a characteristic 
nodular growth showed the disease to be still active. 
2d operation. On May i, 1878, a zone of the bowel including 
this nodule and the cicatrix but not the sphincter was removed 
by operation according to the second method described above 
(page 20) with all the antiseptic precautions recommended by Volk- 
mann. A mass of thickened connective tissue and fat occupying 
the concavity of the sacrum and extending four or five centimetres 
above the seat of the disease in the bowel was also removed. The 
patient made a good recovery, and on June 12th she visited Dr- 
Van Buren’s office ; he found, on examination, “that the wound 
was cicatrizing satisfactorily ; about three-fourths of an inch with- 
in, the finger passed easily through a thread-like ring, marking the 
contracted end of the gut; beyond this, as far as the finger could 
reach, everything was soft and healthy.” 
On examination eight months after the operation a small nodule 
of stony hardness was felt about three centimetres above the anus 
in the tissues behind the bowel. Two months later three nodules 
were found, each as large as the end of the thumb, and together 
forming a mass which was firmly adherent to the sacrum within 
easy reach of the finger. The mucous membrane covering it was 
smooth, adherent, and apparently normal. The patient looked a 
little dragged and yellow, but made no complaint of local pain 
or discomfort. 
At the present time, fourteen months since the last operation, 
the disease is still actively progressing, and the calibre of the 
bowel is so reduced as to admit only the index finger. The pa- 
tient’s condition is tolerably comfortable ; there is no perceptible 
action of the sphincter, but its lack of power has proved no seri- 
ous inconvenience. 
The part removed at the first operation was too sloughy to ad- 
mit of a thorough examination. The part removed at the second 
operation was a somewhat irregular band, averaging five centi- 
metres in breadth, and occupying the entire periphery of the bowel, 
which, when opened out, measured about twelve centimetres. An 
oval portion of its surface, five centimetres in its longest diameter, 
is occupied by a granular, bloody, friable, cauliflower-like mass, and CAXCER OF THE RECTUM. 
25 
surrounded by thickened, finely-papillary mucous membrane. The 
mucous membrane bordering the cicatrix of the first operation 
shows the same thickening and papillary condition on each side 
for distances varying from one to two centimetres. The ulcer and 
the greater part of the cicatrix rest upon and are continuous with 
a firm mass of connective tissue and fat from one to three centi- 
metres thick and containing several enlarged lymphatic glands. A 
vertical section through the ulcer shows that it rests upon a gray, 
finely-alveolar mass of varying thickness, two centimetres at the 
most, without any distinct line of demarkation from the thickened 
adipose tissue except near its edge, where it rests upon a white 
fibrous band one and a-half centimetres long and irregularly con- 
tinuous with the muscular coat. The adjoining fat is streaked 
with white bands and shows two distinct outlying nodules, one of 
them irregular in outline, the other apparently a degenerated 
lymphatic gland. Another lymphatic gland fifteen millimetres in 
diameter and distant more than three centimetres from the ulcer 
and cicatrix shows on section numerous grayish-yellow alveoli 
limited by fine wrhite or bluish septa. 
On microscopical examination the mass underlying the ulcer is < 
found to be composed of round, tubular, and irregular spaces 
lined with cylindrical epithelium, and separated from one another 
by fibrous tissue containing round or oval nucleated granular cells 
in great numbers. The cylindrical cells rest directly upon the 
stroma. Instead of a single row of regular cells there is a double 
or triple row, and the cells nearest the centre of the spaces are 
irregular in form and often globular. The cells are granular 
and contain one or more dark nuclei with several bright nu- 
cleoli. The centre of many of the spaces is occupied by a 
mass composed of highly-refracting, small, irregular bodies and 
fatty epithelium. Many of the cells of the stroma show ad- 
vanced fatty degeneration. 
At the border of the ulcer the mucous membrane shows an ab- 
rupt change ; the finely-papillary condition of its surface is due 
to an increase in the length and diameter of the Lieberkiihn glands 
and a notable increase in the thickness of the submucous tissue. 
Immediately adjoining the edge of the ulcer the tubes suddenly 
become longer and irregular, and plunge down into the submucous 
tissue where they are no longer parallel to one another. The 
muscular coat recedes before the descending glands and disappears 
entirely below the deepest portion of the growth. 
The lymphatic glands show in some places their normal struc- 26 
LEIVIS A. S TIM SON. 
ture and elements, in others a stroma and alveoli similar to those 
found in the primary growth (Figs. 6 and 7). The larger alveoli 
are lined with irregularly cylindrical, the smaller with globular 
epithelium. Many of the alveoli are irregular in outline, and their 
epithelium shows a tendency to infiltrate the adjoining tissue. 
Case III. Under the care of Drs. VanBuren and Keyes. 
Bridget K , an unmarried woman of 30, presented herself with 
a history of a protrusion at stool, 18 months previously, accom- 
panied by slight loss of blood and pain in the back. Her physi- 
cian found the protrusion to be a polyp and removed it. During 
the next six or eight months she remained well ; then the back- 
ache, discomfort in the rectum, and blood in the stools gradually 
reappeared, and she was sent a year later to Dr. VanBuren for ad- 
vice. He found “ several elevated patches with irregularly granu- 
lated surfaces, the largest towards the vagina, and nearly sur- 
rounding the rectum, at from an inch and a-half to two inches and 
a-half from the anus ; the parts movable ; no other evidence of 
disease ; general condition good.” The patient’s mother was suf- 
fering at the time with, and died soon afterwards of, cancer of the 
rectum. The diagnosis of epithelioma was made and its removal 
advised. 
Operation. May 20, 1878, Dr. Keyes removed the lower three 
inches of the rectum, including the anus, and stitched the edge of 
the gut to the skin, using antiseptic precautions and dressings, 
and keeping the lower end of the rectum distended during healing 
by means of an inflated, egg-shaped rubber bag traversed by a 
rubber tube open at both ends to provide for the escape of flatus. 
The bleeding was moderate, and recovery prompt. 
The patient has remained perfectly well ever since, and appar- 
ently suffers no inconvenience from the loss of the sphincter. Dr. 
VanBuren says, “ She has a natural sensation of desire, and a full 
painless evacuation follows ; after this she goes around as usual, 
protected only by a simple compress and napkin.” 
The specimen examined after hardening in alcohol, shows an 
ulcerated finely-granular surface beginning just above the anus 
and measuring two and a-half cent, longitudinally by four laterally. 
This surface is bordered above and on the sides by a coarsely 
papillary, cauliflower-like, overgrown ridge, (Fig. 9), of irregular 
outline, reaching at its greatest breadth a point two cent, higher up 
the gut than the ulcer. There is none of the thickening of the 
para-rectal tissue which was so noticeable a feature in Case II. CANCER OF THE RECTUM. 
27 
Section through the ulcer shows that it is not more than five mm. 
thick (after hardening) ; the surface of this section is a uniform 
gray, without alveoli or mottling, and rests upon the muscular 
coat. 
A section taken from near the surface shows irregular branching 
tubules lined with well-formed cylindrical epithelium, (Fig. 8). 
The tissue underlying the ulcerated surface is composed of young 
connective tissue in which are imbedded irregular tubes, mostly 
of small size, lined with double or triple rows of irregularly cylin- 
drical and globular epithelial cells resting directly upon the 
stroma. The stroma is composed of fusiform, oval, and round 
cells with occasional large, fully developed fibres. Some of the 
culs-de-sac are lined with epithelium which is not in the least 
cylindrical, but is globular or irregular like much of that in 
Case II. 
A section comprising the upper edge of the ulcer and the adjoin- 
ing healthy mucosa, (Fig. io), shows that the first change is the 
enlargement in length and diameter of the tubes ; embryonal ele- 
ments soon appear between the tubes and in the underlying layer 
of connective tissue, and when the border of the ulcer is reached, 
this embryonal tissue is very abundant ; within it are contained 
tubes lined with cylindrical epithelium, of various sizes and run- 
ning in various directions, while underneath the muscular coat is 
nearly doubled in thickness. At a short distance within the edge, 
the surface of the ulcer is composed almost exclusively of embryo- 
nal and half-formed connective tissue ; only a few tubes are found 
near the surface, but in the deeper layers they are crowded thickly 
together. The muscular coat is much thickened and broken up 
into bundles separated by vessels and new connective tissue. This 
dissociation is carried in places almost to the extent of separating 
individual fibres. (Fig. 12). 
, The muscularis mucosa persists under the thickened mucosa be- 
yond the edge of the ulcer until after a large quantity of embryonal 
cells have been formed underneath it in the submucous connec- 
tive tissue, then it disappears, and the tubes extend suddenly down 
into this embryonal tissue and vary greatly in size ; the regularity 
of their epithelium is lost, and the cells are smaller, crowded 
thickly together, globular and opaque. (Fig. n.) 
Section through the papillary portions shows an unbroken, not 
much thickened muscular coat, upon which rests the greatly 
thickened mucosa thrown into folds and papillae by its own in- 
crease. (Fig. 9.) 28 
LEWIS A. S TIM SON. 
Case IV.—“ J. H , 50, married; admitted to the N. Y. 
Hospital, May 18, T878, under Dr. Geo. A. Peters. He is a pal- 
lid but well-nourished man, and has a warty, tubercular growth, 
extending about half an inch from the margin of the anus exter- 
nally, and from one and a-half to two and a-half inches up into 
the bowel, and nearly surrounding it. There is an enlarged gland 
in the left groin. He gives a history of an operation for fistula six- 
teen years ago, and of a lump appearing afterwards, which same 
growth, as he believes, has only lately begun to give him trouble. 
The pain in defecation is now so severe as to require anodyne sup- 
positories, and he demands an operation for its relief. 
“ On May 29th, the operation was done with all the antiseptic 
precautions except the use of the spray. The gut was readily 
brought down and amputated, well beyond the disease, and the 
edges of the stump sewed fast to those of the external circular 
wound. The bleeding was exceedingly moderate. Ample pro- 
vision was made for drainage, and a tube placed in the rectum 
to give vent to gas. * * * The patient did well until 8 
o’clock p. M. on the fourth day, when a severe chill occurred, with 
a rise of temperature to 103.20, followed by sweating. On the 
fifth day there was complaint of pain in the right elbow-joint, and 
at ro o’clock p. M., another severe chill and sweat. On the sixth 
day the temperature rose to 105°, and death took place at 4 o’clock 
p. M. (May 31st).” 
It is to be noted that a chill occurred the day before the opera- 
tion, supposed at the time to be malarial. 
“Body examined at r2 o’clock m. next day. Rounded cicatri- 
ces on the the legs. Drainage tubes in position near incision 
around anus, which looks healthy ; mucous membrane everywhere 
stitched to integument; no union has taken place. Rectum for 
an inch above wound dark-colored and somewhat softened ; above 
this, healthy : no remains of disease ; but little pus, and that not 
t>adly swelling. Right elbow-joint contained a small amount of 
pus. Liver fatty ; no abscesses. Lungs slightly oedematous, no 
abscesses to be found. * * Kidneys shrunken and irregular on 
surface, with several cysts and many scars of old cysts ; cortical 
portion markedly atrophied. 
“ Microscopical examination of the disease removed from the 
rectum shows colloid degeneration of a cylindrical epithelioma. 
Well-marked linear rows of micrococci were discovered between 
the muscular fibres in the heart ; also in the kidney.” CANCER OF THE RECTUM. 
29 
Case V. Personal : Michael I) , 42, unmarried, a large, 
pallid fat man, presented himself June 26, 1878, with complaint 
of painful, difficult, and bloody defecation. Eight months pre- 
viously he had an attack of rectal trouble thought to be due to 
piles ; had bloody and painful stools. Since then he has used 
laxatives and enemata regularly, but defecation has been always 
painful, and the stools frequently bloody. Bougies have been 
passed quite regularly by his physician. 
On examination, the finger encounters a hard, lumpy fold ex- 
tending all around the rectum two centimetres within the anus. 
The upper limit of the tumor can be reached easily on the ante- 
rior surface, but only with difficulty posteriorly. The surface of 
the growth is ulcerated and the finger comes out stained with 
blood. 
Operation, July nth. Total extirpation, including the anus, was 
done by the first method described above (page 19), with full an- 
tiseptic precautions. The para-rectal tissues were found exten- 
sively infiltrated and hard, and firm bands uniting the bowel to 
the sacrum rendered it difficult to bring the former down and 
unite it to the skin without undue tension. Hemorrage was free 
at first, but no vessels required ligation. 
The patient recovered easily from the operation, but on the 
sixth day the sutures were found to have all cut out, and the rec- 
tum to have retracted about two centimetres. Six weeks after- 
wards there was a gap of about four centimetres between the end 
of the rectum and the skin, scattered over which were numerous 
hard granular nodules, evidently a return of the disease. These 
nodules increased rapidly in size, ultimately forming a mass which 
filled the faeces leaving only a narrow central channel through 
which the face passed. The patient sank gradually and died Jan. 
9, 1870. No autopsy allowed. 
On examination of the part removed, when fresh and spread out 
after division longitudinally a little to the left of the anterior 
median line, along a narrow groove where the mucous membrane 
seemed not to be involved, it was found to measure eight centi- 
metres longitudinally and ten centimetres transversely. Along 
the transverse line of little pouches just within the anus the mu- 
cous membrane is raised in a ridge or fold about five millimetres 
high. This ridge is smooth, not ulcerated, and encircles the 
growth except on one side of the groove above mentioned. The 
surface of the tumor is ulcerated, flat, granular, and friable. 
After hardening in alcohol and dividing it along the posterior 30 
LE IVIS A. 5 TIM SON. 
median line, the tumor is found to be two centimetres thick in the 
centre, and composed of a white or bluish stroma enclosing small 
granular alveoli. There is no trace of mucosa on the surface, or 
of muscle on the outside ; at the upper border is a ridge lined with 
thickened mucosa; at the lower border the unaltered anus. In 
some places the ridge is rounded and shows the same structure as 
the body of the tumor ; at others it is simply a fold of much 
thickened mucous membrane with a central (vertical) line of con- 
nective tissue. It is evident that at the thickest part of the tumor 
the line followed in the extirpation was not entirely outside of it. 
On microscopical examination it is found to be composed of 
connective tissue and epithelial elements. The latter are some- 
times cylindrical and arranged in distinctly limited alveoli, but in 
the majority of cases the epithelium is irregular or globular, and 
collected in irregular masses with a marked tendency to infiltrate 
the adjoining tissue. (Fig. 4). 
Case VI.—Dr. Keyes. Mrs. G , 33, was admitted by Dr. 
Keyes to Bellevue Hospital in July, 1878. She sought treatment 
on account of difficulty in defecation which had existed for about 
two years, with frequent desire ; the stools being always painful 
and bloody. 
On examination a hard, lobular mass was found just within the 
anus, entirely encircling the bowel and narrowing its calibre to 
such an extent that the finger could be passed only with difficulty 
through it. The mass was thickest in front and on the left side, 
and was not adherent to the vaginal mucous membrane. There 
was a fistula near the anus communicating with the gut. 
Operation. Total extirpation was performed antiseptically in 
August. During the operation an abscess of some size was found 
in the para-rectal tissues which were much thickened and hard- 
ened. 
Peritonitis developed, and the patient died on the third day. At 
the autopsy the rectum for five centimetres above the point at 
which it had been divided was found thickened and narrowed ; 
the kidneys were large and fatty ; the peritoneum had not been 
wounded. 
The tumor proved on examination to be a cylindrical-celled 
epithelioma. 
Case VII. Personal. Dr. P. Le B. S , 64, married, was 
admitted to the Presbyterian Hospital under my care in Septem- 
ber, 1878, with the following history : In October, 1876, he lost CANCER OF THE RECTUM. 
31 
some blood at stool and felt with his finger a lump inside the anus. 
This vvas pronounced to be a polyp, and partial removal was made 
with an ecraseur shortly afterwards. He continued to lose blood 
in small quantities, and the following May (1877) another partial 
removal was made. His condition gradully grew worse for a year 
and he came to New York in May, 1878, to consult Dr. Van Bu- 
ren, who found a hard irregular mass on the posterior wall of the 
rectum, apparently an epithelioma, and advised its removal. In 
September, 1878, the patient returned to New York for operation 
and was placed under my care by Dr. Van Buren. 
He is a large, fairly-nourished man, who has always had good 
health, but is now anaemic, weak, and dragged-looking ; has never 
been in the habit of using enemata, although habitually constipa- 
ted ; has never suffered from piles until quite recently ; has no 
family history of cancer. 
On examination I find a lobulated mass occuping the posterior 
wall of the rectum, beginning nearly four centimetres above the 
anus ; it is circular, about four finger-breadths in width, and its- 
upper edge, although quite high, can be reached with the finger. 
It is circular, its edge raised and well-defined ; it bleeds easily 
when touched, and is movable on the underlying parts. 
Operation, September 16, 1878. The affected portion of the 
bowel was removed with all antiseptic precautions by the third 
method described above (page 20), the line of incision lying one 
centimetre beyond the border of the tumor, The patient re- 
covered easily from the operation and returned home on October 
12th, with longitudinal incision through the sphincter not entirely 
healed. February 19, 1878, he wrote me that a thorough exami- 
nation had just been made with the aid of a speculum, and that 
the rectum had been pronounced perfectly healthy. There was 
slight prolapse and occasional incontinence of flatus. His gen- 
eral health was better than it had been in two years. I have 
heard from him again recently, and he continues well. 
The tumor, which was so friable that a number of pieces, some of 
them as large as the end of the finger, were broken off during the 
operation, is nearly circular, measuring six centimetres transverse- 
ly, five centimetres longitudinally. Its surface, rising well above 
the level of the adjoining mucosa, is irregular and granular, pink 
and gray in the centre, dark red at the border. Its junction with 
the mucosa looks worm-eaten in places, that is, the edge of the 
latter is free, ulcerated, and marked by a row of small livid 
elevations. 32 
LEWIS A. STIMSON. 
A vertical section through the tumor shows a very vascular up- 
per edge continues with the mucosa, and resting on a white, juicy, 
thick base. The surface of section yields an abundant milky juice 
which shows under the microscope deformed and degenerated epi- 
thelial cells, some of them purely cylindrical, and shreds composed 
exclusively of them. A fresh section from the surface shows it to 
be very vascular granulation tissue containing portions of a few 
tubules lined with cylindrical epithelium. The mucosa adjoining 
the tumor is thickened by increase in the size of the tubes and 
then when the muscularis mucosae is broken through the tubes ex- 
tend abruptly downward into the softened and thickened submu- 
cous tissue. The other histological appearances are identical 
with those described in Case III, (Fig. 10 and n), and therefore 
do not need a separate description here. The muscular coat of 
the intestine is not broken through. 
Case VIII. Under the care of Dr. Chas. K. Briddon. Susan 
S , 36, thin and feeble, admitted to the Presbyterian Hos- 
pital September 14, 1878. Six months ago she began to suf- 
fer with severe pain in the back, and had bloody stools ; 
this condition lasted for two months and was followed by two 
months of relief ; then, two months ago, the symptoms recurred in 
aggravated form and have persisted ; she has intense rectal tenes- 
mus, constipation, and bloody stools. An aunt died of tumor 
of uterus of unknown character. 
On examination the finger encounters at about six centimetres 
from the anus an irregular nodular growth, involving principally 
the posterior surface and right lateral half of the bowel, and con- 
tinuous on the right side with a solid mass as large as a hen’s egg, 
and fixed to the pelvic wall. The upper border of the growth can 
be reached by the finger with difficulty. 
Operation, September 21, 1878. A circular zone, not including 
the anus, was removed according to the second method described 
above (page 19). It was found necessary to open the peritoneum, 
after its recognition, in Douglass’s cul-de-sac to the extent of 
about five centimetres ; this opening was afterwards closed 
with catgut sutures. 
The patient died on the tenth day, after having passed 
through an attack of peritonitis which was controlled by mor- 
phine and cold applications to the abdomen. She was unable 
to retain food, and died of exhaustion. At the autopsy the 
sutures were found to have all cut out, and the pelvic retro- 
peritoneal space was infiltrated with pus. CANCER OF THE RECTUM. 
33 
The affected portion of the rectum was seven centimetres 
in length, and presented a deep, funnel-shaped ulcer with ir- 
regular, raised edges, and some thickening of the adjoining 
mucous membrane ; the ulcer was six centimetres in diameter, 
and four centimetres in depth. The lumen of the rectum was 
contracted to a diameter of fifteen millimetres. The histo- 
logical appearances were similar to those in Case V. ARCHIVES OIF IMIIEIDIOIIINriE 
A BI-MONTHLY JOURNAL 
Edited by Dr. E. C. Seguin, in conjunction with Thomas 
A. McBride, M. D., Lecturer on Symptomatology in the College of 
Physicians and Surgeons, New York, in charge of general medicine ; 
Matthew D. Mann, M. D., Physician to the New York Dispensary, 
Cl ass "for Diseases of Women, in charge of Obstetrics, and Diseases of 
Women and Children ; and Lewis A. Stimson, M. D., Professor of Patho- 
logical Anatomy in the Medical Department of the University of New 
York, in charge of Surgery. 
The Archives of Medicine is designed by the publishers to be in 
some respects a continuation of the “Archives of Scientific and Practical 
Medicine,” formerly issued by them under the editorial charge of Dr. C. 
E. Brown-Sequard and Dr E. C. Seguin, and of the “ American Clinical 
Lectures,” edited by Dr. Seguin, of which the third volume, closing the 
series, was completed in December, 1878. 
The Archives of Medicine will for the present be published every 
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