Reprinted from the Cincinnati Lancet-Clinic, 
December 29, 1894 • 
COLOTOMY AND THE KRASKE OPERATION.1 
BY 
B. MERRILL RICKETTS, M.D., 
CINCINNATI, 
Any operation for cancer of the 
rectum, like that of any other part of 
the alimentary tract, is purely palliative, 
and must be so considered by both the 
patient and the operator. There are 
four things, either one of which would 
justify surgical interference, viz., (1) 
To relieve pain; (2) prolong life; (3) 
prevent hemorrhage; (4) removal of 
offensive matter. That an operation 
will accomplish one or all of these in a 
given case, there can be no question. 
The results thus obtained seem to be 
very much disregarded. The influence 
in this direction is very strong, and not 
to be wondered at when we consider 
the subject from a point of view of 
fatality. At no time during my year’s 
service in the New York Skin and 
Cancer Hospital did I find a case of 
carcinoma of the rectum, uterus or 
breast that did not result in death, with 
or without operation. This experience, 
together with subsequent observation, 
leads me to believe that once carcinoma 
of the rectum always carcinoma of the 
rectum—at least so far as our present 
surgery is concerned. 
I am fully aware that many cases 
are reported in which many years have 
elapsed without recurrence, but I am 
inclined to believe that an incorrect 
diagnosis was given, even though made 
by the aid of the microscope. I do not 
mean to decry the use ol this most 
valuable instrument, for it is not so 
much the fault of the instrument in de- 
termining the character of a growth as 
it is in the eye that views the field. In 
consequence of this fact, I am more in- 
clined to rely upon the clinical history 
and appearance of growths than to the 
character of the growth as found on the 
slide. There is less likelihood of a 
carcinoma being detected in the rectum 
or sigmoid, early in its course, than 
almost any other part of the body. In 
consequence then an early diagnosis and 
removal is not likely to be made; hence 
the invariable rule of fatality with or 
without operation. 
There are two operations from 
which to select: (i) High; (a) low. 
The low operation has reigned supreme 
for many years, simply because of the 
supposed danger in opening the peri- 
toneum. But since it has been found 
that this cavity can be opened with 
impunity, and the advantages of the 
high and the disadvantages of the low 
better understood, more favor is being 
given to the high operation. It has 
been determined by the most frequent 
operators in this class of cases that 
stenosis is sure to follow all excisions 
of the lower bowel, and as stenosis is 
such a terror, accompanied by the 
i Read before the Cincinnati Academy of 
Medicine, December 10. 1894. , 2 
Colotomy and the Kraskr Operation. 
greatest agony every time the bowel is 
evacuated or a sound introduced, one 
can well imagine some of its incon- 
veniences. The removal of the rectum 
or the establishing of a low artificial 
anus by any means, is attended with the 
greatest mortality, suffering and loss of 
time, and the greatest care and atten- 
tion on the part of the attendants. 
consulted Dr. J. F. Heddy, of Glendale. 
His weight diminished from 212 to 120 
pounds. He had the usual symptoms 
of malignant growth within the sig- 
moid. I was asked in consultation, and 
advised, about the 1st of April, a 
colotomy. This was refused, and the 
patient continued to suffer, owing to 
his inability to pass fecal matter through 
the bowels. His condition continued 
to grow worse until August 3, when, in 
the presence of Dr. Heddv, Dr. Edwin 
Ricketts, and others, while under sur- 
gical anesthesia, I proceeded to make a 
lateral colotomy. The gut was found, 
brought into the wound, and sutured 
with silkworm gut. An exploration 
downward showed that the growth was 
about seven inches below the incision 
into the gut. The patient rallied fairly 
well, and expired at the end of seventy- 
two hours from exhaustion. Tempera- 
ture normal. During this time there 
were several fecal discharges. He was 
comparatively comfortable, but could 
not overcome the shock. 
An autopsy was held and it was 
found that an ordinary lead pencil could 
not be introduced through the lumen of 
the gut at the point of disease. The 
bladder wall had become involved, and 
the entire sigmoid was also involved. 
It was also found that the anastomosis 
of the gut and the integument was com- 
plete, and that plastic matter had been 
thrown out, showing that the operation 
itself was a simple and perfect one, and 
had the operation been made thirty or 
forty days before I see no reason why 
death should have ensued. 
LOW RESECTION. 
Disadva n tages. 
1. High mortality. 
2. Infection. 
3. Pain. 
4. Loss of time. 
5. Stenosis. 
6. Fistulas. 
7. Shortening of life. 
8. Difficulty in mak- 
ing operation. 
9. More difficult to 
care for. 
HIGH—COLOTOMY. 
Advantages. 
1. Low mortality. 
2. Less infection. 
3. Less loss of time. 
4. Less pain. 
5. No stenosis. 
6. No fistulas. 
7. Life more prolonged. 
8. Ease of making 
operation. 
9. More easily cared 
for. 
Unless immediate action is demanded 
the results are more favorable and the 
operation of colotomy simplified by 
making it at two sittings. 
Its indications when the sigmoid or 
rectum is involved: (1) Malignant 
growths; (2) non-malignant growths; 
(3) severe ulceration; (4) prolapsus; 
(5) congenital malformation. An arti- 
ficial anus may thus be formed and 
closed as the case may require. The in- 
guinal colotomy is to be preferred, 
especially in adults, as the descending 
colon is so often out of its natural 
position—a condition due to the elonga- 
tion of the mesenteric attachment, which 
often allows the colon to reach the 
median line, thereby making the lumbar 
operation impossible without opening 
the peritoneal cavity. Besides, the in- 
guinal opening is more easily cared for. 
Having recently made each of these 
operations, I herewith append short 
reports. 
COLOTOMY. 
CASE 11. 
Thomas C., referred to me by Dr. 
Wilkinson, of Sabina, aged forty-four, 
white, farmer, in a fair physical con- 
dition. He has complained for about 
ten months with some trouble about the 
rectum. A malignant growth was sus- 
pected. He had lost flesh, the pain 
upon evacuating his bowels became 
greater, and it was soon found that his 
bowels could not be evacuated without 
a strong cathartic at frequent intervals. 
On September 30, in the presence of 
Dr. Wilkinson and others, I proceeded 
to make the operation as suggested by 
case 1. 
Mr. H., aged sixty-four, white, a 
farmer, has complained for about fifteen 
months of trouble within the lower 
bowel. He consulted an advertising 
specialist, who touched his rectum oc- 
casionally with a red-hot iron for ulcera- 
tion. fie gradually failed, and finally COLOTOMY AND THE KRASKE OPERATION. 
Walker, of Detroit, provided the con- 
ditions were favorable. I found that 
the malignant gowth was low down, 
involving not only the inner but also the 
lower sphincter. An incision was made 
from above downward, to either side of 
the coccyx, intending to divide the 
coccyx at its fourth ring, leaving the 
periosteum intact for a hinge, and turn 
it back with the integument. Upon 
reaching the rectum I found that at least 
three inches and a half of it was in- 
volved, and that it was necessary for 
me to abandon the idea of using the 
Murphy button. I removed the lower 
end of the rectum, leaving about three 
inches to draw into the wound. I re- 
moved all of the diseased tissue that I 
could find, making it as thorough as 
possible. I removed the coccyx and a 
portion of the flap, brought the rectum 
out of the lower end of the remaining 
coccyx, and sutured the walls of the 
integument as close down upon the 
rectum as possible, the sutures being 
silkworm gut. The patient has made 
an uninterrupted discovery, and he has 
had comparative ease. He left my 
private hospital for home at the end of 
the fourth week, in a very favorable 
condition—indeed, his suffering being 
practically nil. It has not been neces- 
sary to give opiates in any form but 
a few times during his entire con- 
valescence. 
A letter received from his attending 
physician a few days ago states that the 
patient has gained a great deal in flesh, 
and that he is walking about in a most 
excellent general condition. He has no 
difficulty in evacuating his bowel, over 
which he has control. Had I had a 
more thorough knowledge of the con- 
dition of this rectum before I operated, 
I should have made the inguinal colot- 
omy; however, as the disease has prob- 
ably existed for a year, I feel that the 
operation applied will answer every 
purpose until dissolution takes place, 
which I believe will be before any great 
amount of stenosis occurs. 
“ The Trinidad,” 137 Broadway.