Excision of Cancer of the 
Rectum. 
BY 
ANDREW J. McCOSH, M. D., 
NKW YORK. 
BKPBINTED FKOS1 THE 
XfU) York fttcfiiral Journal 
for September 3, 1892. Reprinted from the flew York Medical Journal 
for September 3, 1802. 
EXCISION OF CANCER OF THE RECTUM * 
By ANDREW J. MoCOSII, M. I)., 
NEW YORK. 
While the treatment of cancer of the rectum is not fol- 
lowed by brilliant results, yet it must be acknowledged that 
operative procedures are followed in the majority of cases 
by prolongation of life and alleviation of pain, and in a few 
cases by permanent cure. Surgery offers two plans of treat- 
ment—radical and palliative. In many of the cases which 
fall into the surgeon’s hands radical treatment is impossi- 
ble, in others it is questionable, while in a considerable num- 
ber it is demanded. It is generally accepted that radical 
measures should be adopted in cases where the disease is 
confined to the lower three inches and a half or four inches 
of the rectum, or, in other words, when the finger can reach 
above the cancer, provided it has not extended to other 
organs. Are our operations, however, to be confined to such 
cases ? Is there a point higher than which we must not vent- 
ure, and, if there be such a limit, where is it ? In cases 
where the disease extends higher than four inches, or where 
the average index finger can not reach healthy gut above it, 
all surgeons are not agreed as to the propriety of excision. 
* Read before the New York Surgical Society, April 13, 1892. 
COPYKIGHT, 1892, BY D. APPLETON AND COMPANY. 2 
EXCISION OF CANCER OF THE RECTUM. 
Especially is this the case if it be certain that the peritoneal 
cavity must be freely opened during the operation. In such 
cases, even when other conditions are favorable, some sur- 
geons advise the adoption of the palliative operation of co- 
lotomy. It is especially the English who hold this view, 
and they prefer to give a certain amount of temporary relief 
by means of a colotomy rather than subject the patient 
to the dangers of a high operation on the rectum. Thus 
Treves * says : “In no case should the peritonajum be de- 
liberately opened, or a portion of the vagina, bladder, or 
prostate excised. Experience has condemned these exten- 
sive operations.” Allingham f expresses himself as follows ; 
“ To attempt to excise the rectum when the .growth is four 
inches up the bowel is most unscientific and unsurgical, as 
it subjects the patient to great risk, and, moreover, it proba- 
bly only partially removes the growth.” Cripps, at the 
same meeting, says : “If the finger can pass sufficiently be- 
yond the disease to feel a healthy mucous membrane so far 
as the height is concerned, a satisfactory removal is possi- 
ble.” In his further remarks he discourages operation on 
cases where the disease extends beyond the reach of the 
finger. The great majority of English surgeons hold this 
same view. 
German surgeons, on the other hand, do not hesitate to 
operate on cases where the disease extends much higher 
than four inches and where the peritoneal cavity must be 
freely opened. Indeed, they would hardly be influenced by 
this latter fact. I do not know that there is any operation 
for the perfection of which we are so much indebted to our 
German colleagues as this very one of excision of the rec- 
tum. They certainly deserve almost the entire credit for 
the establishment of this operation on a proper basis. 
* Operative Surgery, p. 691. 
| Brit. Med. Jour., 1889, p. 806. EXCISION OF CANCER OF THE RECTUM. 
3 
Our American practice has not been so clearly formu- 
lated. We are perhaps in the transition stage from the con- 
servative English to the radical German view. While the 
majority of surgeons in this country do not take such an 
exti'eme position as do the Germans, yet few of us would, I 
think, be willing to be restrained by the limits with which 
the English up to the present time have surrounded the op- 
eration. So little has been published on this topic that it 
is difficult to say just where we stand. It is certainly, how- 
ever, only within the last few years that we have held such 
advanced views, while in Germany, as far back as 1874, stress 
has been laid by Yolkmann and others on the good results 
obtained by radical treatment in cases where the disease ex- 
tended high up in the rectum, and ever since their surgeons 
have ably maintained this position, which no doubt has in- 
fluenced in a great measure our practice in this country. 
On account of our meager literature on this subject, it is 
important that all cases should be published, and for this 
reason I report the following live cases, which cover my ex- 
perience during the past three years. 
Before giving the cases in detail I shall describe in a 
few words the general plan of procedure followed in all five 
operations. A vertical incision is made in the median line 
from the posterior border of the anus backward as far as the 
tip of the coccyx, and, if necessary, extended upward as far 
as the middle of the sacrum. If the lower part of the rec- 
tum is healthy and does not need removal, this incision is 
deepened until the posterior part of the rectum is exposed. 
The gut is then divided across below the disease, leaving its 
lower segment attached to the anus. If this segment is not 
more than an inch or two in length, it is better to divide it 
with the sphincter muscles vertically through its posterior 
wall. In other words, prolong the original incision through 
the posterior border of the anus. If the lower part of the 4 
EXCISION OE CANCER OE THE RECTI M. 
rectum is diseased and needs removal, it is left unopened 
and two semicircular incisions are carried around it, meeting 
on the perinseum in front of the anal opening. In either 
case a ligature is tied around the lower end of the rectum 
to prevent escape of ffecal matter and to be of assistance in 
handling the gut. 
If the incision to the tip of the coccyx does not give 
sufficient space, then the coccyx is removed, and, if neces- 
sary, the lower part of the sacrum. The separation of the 
diseased rectum from neighboring tissues is then carried 
on until healthy gut is reached above the disease. This 
dissection should be mainly “ blunt,” and should be done 
by the fingers and blunt-ended scissors. If accomplished 
in this way, but few blood-vessels require to be clamped 
and still fewer ligatures to be applied. Sponge pressure, 
kept up for a few moments while the operator attacks an- 
other district, will generally be sufficient to control the 
greater part of the haemorrhage. This is preferable to the 
use of artery forceps, as not only is time saved—an impor- 
tant detail in these operations—but also the field of opera- 
tion will not be blocked by a dozen or more of arterv 
clamps. It will sometimes be found useful to clamp a con- 
siderable amount of tissue in a large artery clamp and se- 
cure it either by a ligature eii masse or by leaving on the 
clamp until the end of forty-eight hours. In an average 
case three to six vessels require to be secured, occasionally 
ten or a dozen. 
When complete separation of the rectum as far as the 
upper limit of the cancer has been accomplished, the next 
step will depend upon the condition of its anal portion. If 
this lower segment must be removed, the entire gut is 
drawn down until the disease is beyond the margins of the 
external wound, and the rectum is then amputated at a 
point an inch above the upper limit of the cancer, and the EXCISION OK CANCER OF THE RECTUM. 
5 
cut end united by sutures to the edges of the external 
wound. If the lower part, with the anus and sphincter 
muscles, has been saved, the segment of rectum containing 
the cancer is resected, thus leaving a portion of healthy 
gut to which the lower end of the proximal portion is sut- 
ured. If the lower segment has been split, its edges can 
be sutured together immediately, or this may be post- 
poned for a future operation. The external wound is 
then closed partially by suture, drainage being effected 
by tubes or iodoform gauze. If the peritoneal cavity has 
been freely opened, no attempt is made to close the open- 
ing by suture, but the wound below is packed with iodo- 
form gauze. 
If possible, the bowels are kept constipated for four or 
five days after the operation, and during this time the gauze 
packing is left undisturbed. After the bowels have been 
freely moved the gauze is taken out, the wound irrigated, 
and fresh gauze inserted. For several days previous to the 
operation an attempt is made, by repeated doses of mild 
cathartics, to thoroughly empty the intestinal tract, and if 
this has been possible there will not generally be much 
difficulty in preventing a movement of the bowels for five 
or six days following the operation. 
Case f. Excision of Four Indies of Rectum.—Male, aged 
forty-nine; had enjoyed good health until a year ago, .when he 
began to suffer pain about the anus. Since then the pain has 
increased, and he suffers from constipation and occasional 
bloody stools. For the past two months there has been 
marked loss of flesh and strength and obstinate constipation* 
On examination, a hard nodular mass is felt beginning just 
above the sphincter and extending upward about two inches and 
a half. At a point an inch and a half above the anus there is 
a constriction which will not admit the finger. The mucous 
membrane covering the growth is ulcerated. 
Operation in Presbyterian Hospital in May, 1890. Ether. 6 
EXCISION OF CANCER OF THE RECTUM. 
Lithotomy position. Sound in urethra. Vertical incision from 
tip of coccyx to anus, which is surrounded by two semilunar 
incisions. Dissection carried upward well above the cancer. 
Rectum drawn downward and divided three quarters of an inch 
above the disease at a point four inches above the anus. Cut 
end of rectum drawn down and fastened to margins of wound 
by silk sutures. Peritoneal cavity not opened. Large rubber 
drainage-tube behind the rectum and remainder of wound 
united by suture. Primary union of rectum to skin of edges of 
wound in part only. Wound healed in twenty-seven days and 
patient discharged cured. Greatest elevation of temperature, 
lOO'S0. In March, 1892 (twenty-two- months after operation), 
patient was in perfect health. Two movements from bowels 
occur daily, which he can control fairly well unless he has 
diarrhoea. 
Case II. Excision of Three Inches of Rectum.—Male, aged 
fifty seven. History of constipation for two years. For past 
six months pain in rectum, blood in stools, and emaciation. 
On examination, ulcer on posterior edge of anus, with indurated 
edges and hard nodular mass extending about two inches up 
the rectum. Mucous membrane for lower inch ulcerated, bleeds 
freely, and painful to the touch. Operation, July, 1889. In- 
cision from tip of coccyx to perinteum surrounding anus by two 
semicircular incisions. Dissection of rectum upward for three 
inches, where divided well above the cancer. Peritonaeum not 
opened. Cancer peeled off urethra, to which it was in close 
approximation, but neither bladder nor urethra opened. Cut 
end of rectum drawn down and sutured to skin. External 
wound closed by sutures, except at anterior extremity, where 
a small drainage-tube was placed, and at posterior extremity, 
where a large tube was used. Tubes removed at end of forty- 
eight hours. Primary union of skin wounds. Slight retraction 
of rectum—perhaps half an inch. Patient left the hospital 
cured at end of four weeks. Three months later was well and 
had excellent control of bowels, except when he had taken a 
cathartic. Patient has since disappeared. 
Case III. Excision of Six Inches of Rectum.—Female, single, 
aged twenty. For one year pain in rectum and obstinate con- EXCISION OF CANCER OF TIIE RECTUM. 
7 
stipation. During the past three months rapid loss of tlesh and 
strength. Patient very anaemic and feeble. On examination 
of the rectum, on its anterior wall just above the sphincter is an 
oval ulcer with broad hardened base and excavated center run- 
ning upward for two inches. The mass is adherent to the pos- 
terior vaginal wall. By vaginal examination, high up behind 
the uterus, apparently adherent to its fundus, is a hard tumor 
the size of a hen’s egg, supposed to be a uterine fibroid. 
Operation, April 16, 1891, in Presbyterian Hospital. Ether. 
Lithotomy position. The perinseum was divided transversely 
close behind the posterior vaginal wall, and, the anus being en- 
circled, the incision was extended backward as far as the lower 
part of the sacrum. Coccyx excised. Lower end of rectum 
tied by a ligature. The lower two inches of posterior vaginal 
wall, where adherent to the ulcer, was left attached to the rec- 
tum. Peritoneal cavity opened in Douglas’s pouch, just behind 
cervix uteri, and the hard mass supposed to be a fibroid was 
found to be a separate cancerous deposit on the rectum, slightly 
adherent to the uterus. The rectum was easily freed on its pos- 
terior aspect, and the mesorectum being divided for about two 
inches and several glands removed, the rectum was drawn 
downward and cut across well above the cancer at a point six 
inches above the anus. The cut end of the gut was sutured to 
the skin about the middle of the wound. The wound was sut- 
ured at the anterior and the posterior parts of the incision, and 
the cavity packed with iodoform gauze. The rectum united to 
the skin by primary union, and also the edges of the wound 
where sutured. She made a good recovery, and left the hos- 
pital on May 16th. The functional result was good; she had 
perfect control of gas and faeces under ordinary circumstances. 
There wras no sign of local return, and for seven months she was 
in excellent health. She then complained of abdominal disten- 
tion, the liver began to enlarge, and ascitic fluid to collect, and 
she died from cancer of the liver, nine months after operation. 
In this case colotomy would have probably given her an equal 
length of life, but up to the time of her death she wms entirely 
free from local pain, and I doubt if this would have been the 
case had colotomy been performed instead of excision. 8 
EXCISION OF CANCER OF THE RECTUM. 
Case IV. Excision of Ten Inches of Rectum ; Sphincters re- 
tained', to which the Rectum teas united by a Secondary Opera- 
tion.—Female, aged thirty-seven. Habitual constipation for 
two years. Pain in back and left side, and loss of flesh and 
strength during the past six months. On examination, a hard,, 
nodular, annular stricture of rectum, two inches above the anus. 
Extending upward beyond tbe reach of the finger is a large 
nodular mass. Under ether the finger could not pass through 
the constricted portion, and in the vagina could not reach the 
upper limit of the tumor. 
July 3, 1891.—Operation in the Presbyterian Hospital. 
Ether. Patient in knee-elbow position. Incision from tip of 
coccyx to posterior border of anus. Dissection carried down 
until the posterior surface of the cancerous rectum was reached. 
An attempt was made to leave undivided the lower inch and 
a half of rectum, but, in order to define the limits of the disease, 
the sphincters and lower inch of the rectum were divided 
posteriorly. The dissection was carried upward until the 
lower two inches and a half of the rectum were freed. At 
this point the tumor bulged out into each ischio-rectal fossa 
and was difficult to separate from the neighboring tissues. In 
passing the finger around the tumor to free it from its attach- 
ments on the left side, an artery was torn across and a tremen- 
dous haemorrhage took place before the vessel could be seized 
by a large clamp in the midst of hardened tissue. The vessel, 
from the size and force of the jet, must have been abnormally 
large. The clamp was left in situ. In the mean time a 
ligature had been tied around the rectum just below the 
disease, and the gut was cut across below it, leaving the lower 
inch with the sphincter muscles undisturbed. This lower 
portion was then split vertically through its posterior bor- 
der, and, remaining attached in front and at the sides, was 
drawn apart with the margins of the wound. To give more 
room, the coccyx was excised and the lower inch of the sa- 
crum removed by cutting that bone across by bone forceps at 
the level of the fourth sacral foramen. The patient’s condition 
was not good, and the remainder of the operation was done 
rapidly. The peritoneal cavity was freely opened, the meso- EXCISION OF CANCER OF THE RECTUM. 
9 
rectum drawn down and divided for three or four inches, a few 
hardened glands removed, the rectum drawn well down and 
divided across above the cancer at a point eight inches above 
the anus. It was intended to fasten the cut end into the 
sphincter, which had been left attached to the skin, but the pa- 
tient was suffering from so much shock that the cut end of the 
gut was fastened to the skin about the middle of the wound by 
a few sutures. The margins of the posterior part of the wound 
were approximated by a deep suture, and the cavity packed 
with iodoform gauze. No vessels had been tied, but four artery 
clamps were left in the wound. The patient rallied from the 
operation. The bowels could not be controlled, and from the 
third to the sixth day there was considerable elevation Of tem- 
perature, but at the end of a week the condition of the patient 
and of the wound was satisfactory. The rectum did not unite 
writh the skin, and its lower inch necrosed. In order to surround 
the lower end of the rectum with its sphincter muscle, ou July 
28th a second operation, under ether, was performed. There was 
a healthy granulating cavity through which the rectum passed, to 
within an inch of the skin. The wound was irrigated, the adhe- 
sions surrounding and fastening the rectum in its new position 
were freely broken down by the finger, and the peritoneal cavity 
reopened. The gut was drawn down by dividing the mesorectum 
still further, until its £nd projected well beyond the skin margin. 
An inch was then removed from its lower end, so as to be sure 
that all diseased tissue was removed. The inner surface of the 
sphincter muscles, which at the first operation had been left at- 
tached to the skin, was then denuded and the end of the rectum 
implanted within the denuded surface, and the circle of the 
muscle completed behind by suturing its ends together. 
Deep sutures of silver wire approximated the posterior mar- 
gins of the wound, the remainder being packed with iodoform 
gauze. The patient suffered hut little from shock after the sec- 
ond operation. On August 23d she left the hospital, the wound 
being nearly healed. On September 11th the wound was com- 
pletely healed. The end of the rectum had united with the 
sphincter muscles, and while the grip of the muscle was not 
perfect, yet it was sufficient to give the patient fair control over 10 
EXCISION OK CANCER OF THE RECTUM. 
her bowels. On April 3, 1892, the patient reported she had 
gained thirty pounds since the operation and her general health 
is excellent. She has no pain and no sign of local recurrence. 
Except when she has loose diarrhoeal movements, she exercises 
perfect control over her bowels. She affirms that she is as well 
as at any period of her life. Microscopical examination declared 
the tumor to he a carcinoma. 
Case V. Excision of Seven Inches of Rectum.—Female, aged 
sixty-three. History of constipation for several years. For the 
past six months rectal pain and loose blood-stained movements. 
On examination, beginning an inch and a half above the anus, 
was an irregular, hard, nodular mass constricting the lumen of 
the rectum, so that the finger could not pass farther than two 
inches and extending upward beyond the reach of the finger 
into the hollow of the sacrum. 
Operation, August 3, 1891, in the Presbyterian Hospital. 
Ether. Lithotomy position. Incision began just behind the 
anus and ran backward as high as the middle of the sacrum. 
The sphincters were found infiltrated, and two semicircular in- 
cisions were made surrounding the anus and meeting on the 
perinaeum. The incision was still further extended through the 
perimeum, dividing the lower inch and a half of the posterior 
wall of vagina. The lower part of the rectum was tied with a 
silk ligature. The dissection of the rectum from neighboring 
tissues was difficult. In front it was adherent to the vagina, 
part of which was removed. Behind, the mass was adherent to 
the anterior surface of the sacrum as far up as the promontory. 
To give access to this region, the coccyx and the lower inch 
and a half or two inches of the sacrum were removed by cut- 
ting across the latter bone by bone forceps at the lower border 
of the third sacral foramen. The peritoneal cavity was freely 
opened, and, after dividing the mesorectum, the diseased rectum, 
which formed a very bulky tumor, was drawn down and the 
gut divided an inch above the cancer at a point about seven 
inches above the anus. Two large indurated masses, consisting 
of enlarged glands and infiltrated fat, were afterward removed. 
Hardened and probably diseased tissue was felt running upward 
and to the right, but no attempt was made to remove it on ac- EXCISION OF CANCER OF THE RECTUM. 
11 
count of tlie condition of the patient. The cut end of the rec- 
tum was fastened by silk sutures in the center of the wound. 
A deep suture was inserted at the posterior part of the wound 
to approximate the margins. The anterior part of the wound, 
consisting of what remained of the vagina and perinseum, was 
united by suture. No vessels were ligatured, but four clamps 
left in position. The cavity was packed with iodoform gauze. 
The patient rallied well from shock. The highest temperature 
after the operation was 101'4°. 
August 30th.—Union by secondary intention throughout the 
posterior part of wound. Union had been primary throughout 
its anterior portion. 
September 15th.—Wound entirely healed and patient able to 
walk. 
The pathologist reported that the tumor was a carcinoma. 
During the operation I felt that the case was not a suitable 
one for excision and that colotomy would have been the wiser 
procedure. I formed this opinion on account of the extensive 
and firm adhesions of the tumor on all sides, especially at the 
lateral borders of the sacrum. I felt that 1 was working in 
dangerous territory and that removal of all the cancer was im- 
possible. The subsequent condition of the patient has shown, 
however, that excision has given greater comfort than would 
have colotomy. In February (seven months after operation) 
the patient was alive and comparatively well. Her general 
health has improved and she suffers but little pain. She has, 
however, but very imperfect control over the rectum. 
There are a number of steps in the operation about 
which there is considerable difference of opinion. 
1. The Incision.—Many different methods of approach 
to the disease have been employed during the past century 
without, perhaps, much difference in the results obtained. 
Since, however, the plan of attacking the growth from be- 
lli nd rather than from below has been introduced, opera- 
tions can now be performed with comparative safety which, 
fifteen years ago, would have been considered as unjustifia- 12 
EXCISION OF GANGER OF THE RECTUM. 
ble. While the sacral method is appropriate in a consid- 
erable number of cases, yet many satisfactory operations 
can be done without encroaching- on that bone. Of the 
many methods of approach, it may not be amiss to men- 
tion a few of them. Tlie oldest method is that of Lisfranc. 
He made two semilunar incisions around the anus, and car- 
ried the dissection upward. Hueter made a horseshoe shaped 
incision, the bow in front of the anus and the arms running- 
backward. Separation of the gut begins in front, and it is 
then divided across below the disease, and the flap con- 
taining the anus and sphincter muscles thrown backward, to 
be replaced after excision of the diseased segment. 
Velpeau made his incision from the tip of the coccyx 
downward through the posterior part of the anus, and the 
tumor can then be seen and handled from the interior of 
the gut. 
Kocher * makes a long posterior incision from the coccyx 
to the edge of the anus, and removes the coccyx if neces- 
sary. Dissection is carried down till the posterior wall of 
the rectum is exposed, and the daps are held apart by re- 
tractors. If the cancer does not involve the anus, the pos- 
terior healthy rectal wall, with the sphincters, is cut through 
vertically as high as the point where the gut is to be divid- 
ed below the cancer. Tf the anus is diseased it is excised 
with the rectum. 
The sacral methods have many distinct advantages. By 
adopting one or other of these, freer access is gained to the 
disease. The opening through which we work being larger 
and leading more directly to the seat of cancer, our manipu- 
lations can be carried on by sight rather than by touch. A 
much higher point on the rectum can be reached, even above 
the sigmoid flexure. If suture of the cut ends be neces- 
* (Jtrlhl. f. Chir., 1874. EXCISION OF CANCER OF THE RECTUM. 
13 
sary, this can be accomplished directly under the eye of the 
operator. 
There may be disadvantages, but they are certainly 
more than counterbalanced by the undoubted advantages. 
It is alleged against the method that by it the pelvic floor 
is weakened, that there is greater tendency to prolapse of 
the bowel, and that, by disturbance of the sacral nerves, 
the functional control of the rectum must be lost. The 
first two objections, however, are largely theoretical, and 
even were the last a valid one, it can not be considered as 
important, for the control over the sphincter muscles after 
any rectal operation is apt to be very imperfect. In all 
sacral operations certain of the nerves must be divided, and 
it is not a matter of indifference which ones are sacrificed. 
In this connection it will not be amiss to make the follow- 
ing statements, which, I think, are correct: Division of 
the posterior branches of the sacral nerves is of little mo- 
ment, as no important tissues are supplied by them. 1 )i- 
vision of the anterior branches of the fifth nerve is also 
unimportant. Division of the anterior branches of the 
fourth nerve, if confined to one side, is not followed by seri- 
ous disturbances. Division of the anterior branches of the 
third nerve should be avoided, as they enter into the forma- 
tion of the ischiadic plexus, and serious changes in the in- 
nervation of the pelvic organs are liable to follow injury of 
either of these branches. 
The most prominent of the sacral methods are as fol- 
lows : 
1. Kraske's Operation*—The patient is placed on the 
right side. The incision begins in the median line, at the 
middle of the sacrum, and extends downward to the anus. 
The soft parts being retracted from the bones, the lower 
part of the insertion of the left glutaeus maximus muscle is 
* Arch. f. Min. Chir., Bd. xxxiii, p. 568. 14 
EXCISION OF CANCER OF THE RECTUM. 
loosened from the side of the sacrum. The coccyx is ex- 
cised. The lower part of the sacro-sciatic is divided. 
The lower part of the left wing of the sacrum is then 
cut away with the chisel, following a bowed line which 
begins on the left edge of the bone, at the level of the 
third sacral foramen, and curves inward and downward 
along the lower border of this foramen, and then around 
(on the median side of the left fourth foramen) and down 
to the end of the bone. After the bone is made smooth 
the patient is placed in the lithotomy position, and, the tis- 
sues being retracted, the cancer is freely exposed. 
2. Bardenheuer's Method.*—The patient is placed in the 
lithotomy position. The incision runs from the middle of 
the sacrum to the anus and through the sphincters. The 
soft parts are separated from the coccyx and lower part of 
the sacrum until the edges of the bone are exposed. The 
ligaments are divided. The sacrum is then cut transversely 
across, just below the third sacral foramen. The soft parts 
may be divided by a transverse incision on each side if 
more space be needed. 
3. Heineke's method f was devised because he feared that 
removal of so much bone would weaken the floor of the 
pelvis, lie divides the sacrum vertically, and afterward 
unites the lateral halves by suture. His incision extends 
from the level of the third sacral foramen down below the 
tip of the coccyx, and from the upper end of this a trans- 
verse incision is carried outward on each side. The bones 
are then sawed through vertically in the median line as 
high as the fourth sacral foramen (found by probing), and 
at this point the sacrum is sawed transversely across and 
each half retracted. After excision of the cancer the bones 
are united by sutures. 
* Sammlung Min. Vortriige, No. 298. 
f Munch. »ied. Woch., 1888, No. 87. EXCISION OF CANCER OF THE RECTUM. 
15 
4. Kocher $, Method (reported by Arnd).—The incision 
extends in the median line from the level of the posterior 
superior spine of the ilium downward as far as the coccyx. 
On each side the soft parts are separated from the bone as 
far laterally as the posterior sacral foramina and as high as 
the third foramen. By means of the chisel a groove is 
then cut on each side of the sacrum along the inner edges 
of the foramina, beginning at the third and extending to 
the end of the bone. The flat segment of bone 
spange) included between these lines and consisting of the 
posterior layer of the bone is then removed, which freely 
opens the spinal canal. The course of the sacral nerves 
can then be plainly seen, and they can be drawn aside, so as 
to be safe from injury during the operation. The sacrum 
and coccyx are then divided vertically in the median line, 
by means of a saw', as high as the third foramen, at which 
point the bone is divided transversely and, the important 
third and fourth nerves being carefully guarded, each half 
of the sacrum is drawn aside and the rectum freely exposed. 
When the diseased rectum has been removed, the lateral 
halves of the bone are approximated and sutured. 
5. Levy's Method.*—A transverse incision is made a 
finger-breadth above the cornua coccygea, from each end of 
which incisions run downward for 8 ctm. through the glu- 
taeus magnus muscle. The ligaments are divided, and the 
connective tissue separated from the anterior surface of the 
sacrum. This bone is then cut across opposite the trans- 
verse skin incision, and the flap, in which is the lower part 
of the sacrum and the coccyx is drawn downward and, 
after the cancer has been excised, is replaced, and the bones 
united by suture. 
This operation has been slightly modified by Delbet and 
by Jaennel (Gaz. hebdom. de med. et de chir., 1890, p. 569). 
* Ctrlbl. f. Chir., 1889, No. 13. 16 
EXCISION OF CANCER OF THE RECTUM. 
Methods which do not injure Bone. — Zuckerkandl * 
places the patient on the left side, and begins his incision 
at the tuberosity of the ilium and extends it along the left 
edge of the sacrum, slightly bowed toward the right, down- 
ward into the ischio-rectal space, where it ends midway be- 
tween the anus and tuberosity of the ischium. 
Wolfierf makes a somewhat similar incision, begin- 
ning on the right side of the sacrum, a little above the 
coccyx, one to two centimetres external to it, and extends it 
downward, with a slight concavity toward the right, to near 
the anus, and it ends at a point on the perinamm corre- 
sponding to the posterior commissure of the vulva. This 
incision keeps closer to the sacrum than Zuckerkandl’s, and 
ends nearer the perinseum. 
Lange J advocates an operation which, in certain eases, 
may prove of great assistance in allowing the cut ends of 
the rectum to be united by circular suture. He makes his 
incision from one tuber ischii to the other, across the peri- 
naeum in front of the anus, and carries it deep enough to 
allow the whole muscular apparatus of the anus, with the 
lower segment of the rectum, to be pushed upward for two 
or three inches, so as to bring the cut ends of the gut into 
easy apposition. It is applicable in cases where the upper 
end of the rectum can not be easily brought down to the 
anal portion. 
In cases of extirpation shall the cut end of the rectum 
be sutured to the skin ? Many surgeons say it should not. 
Thus Cripps # says: “ I consider that the risks of both peri- 
tonitis and cellulitis are greatly increased by the practice of 
drawing down and stitching the cut end of the bowel to the 
* Wien. Min. Woch., 1889, Nos. 14 to 18. 
f Ibid., Nos. 15 and 16. 
\ K. Y. Med. Jour., 1891, p. 309. 
# Brit. Med. Jour., October 12, 1889. EXCISION OF CANCER OF THE RECTUM. 
17 
margin, for, owing to much bruised tissue, many ligatures, 
and the inevitable tension on the gut, primary union is most 
unlikely to occur.” I can not agree with this view. It cer- 
tainly seems to me a wise procedure to suture the rectum to 
the margins of the wound, and I think it should always be 
done. The faecal matter will thus be guided through its 
proper canal to its point of exit, whereas, if the gut be left 
in situ, it will have to work its way out for three inches 
through a funnel the walls of which consist of a raw sur- 
face recently made in cellular tissue where a certain amount 
of infection is liable to occur in spite of enforced constipa- 
tion, gauze packing, or frequent antiseptic irrigation. If 
the rectum is properly loosened above—and it is most im- 
portant that this should always be done—there ought to be 
but little tension on the sutures. Experience has shown that 
it is but seldom that recession of the rectum thus fastened 
takes place. Arad* collected 110 cases where the gut was 
sutured to the skin, and out of these 9 died, a mortality of 
8T8 per cent. In 17 cases where the gut was not sutured 
8 died, a mortality of 18-6 per cent.; but he adds 18 other 
cases where the same result was brought about by tearing 
out of sutures and escape of faeces after circular suture with 
4 deaths, which brings the mortality to 20 per cent. 
When the peritoneal cavity has been freely opened, 
how shall the opening be occluded l Shall it be carefully 
closed by suture or shall the cavity be simply packed with 
antiseptic gauze without any attempt at suture ? Some sur- 
geons prefer the first, others the second plan. The results 
do not seem to differ to any great extent. The complete 
suturing consumes valuable time, and if blood or other se- 
cretions have been left within the cavity they can not escape, 
and therefore drainage is less perfect than if the cavity is 
left unsutured and gauze packed below to shut it off from 
* Dent. Zeitsch. f. Chir., lid. H!2, p. 1. 
i! 18 
EXCISION OF CANCER OF THE RECTUM. 
infection after the operation. If sutures are employed there 
is less danger, however, of after-infection. My own feel- 
ing is that the packing of the cavity with mild iodoform 
gauze is the safer method. Stierlin * has collected 26 cases 
where the peritonaeum was sutured, with 20 recoveries, = 77 
per cent., and 26 cases where no sutures were employed, 
with 16 recoveries, = 61'5 per cent. 
Is it wise to take special pains to preserve the lower 
part of the rectum ? Are the results as to mortality and 
freedom from recurrence as good when this is done ? Is 
the functional result decidedly better ? It is not easy to 
answer explicitly these questions. If the lower portion of 
the gut is left it is necessary to unite the two ends by cir- 
cular suture. These sutures are apt to tear out and then no 
advantage has been gained. In fully one half the cases leak- 
age has resulted, and then an artificial anus is established and 
the sphincters are useless. Thus in 5 cases of suture by 
Billroth,f leakage resulted in 3. Arnd J collected 15 cases 
of circular suture, and in 8 of these the sutures tore out. 
More time is consumed in the operation when the circular 
suture is done, and, unless the functional result can be shown 
to be decidedly better, it seems to me that we should not 
be too anxious to preserve the lower part of the rectum. 
Heineke # thinks it better to remove the lower part of the 
rectum on account of the liability for the sutures to tear out 
and because of subsequent contraction. Von Bergmann || 
does not deem it important to save the sphincters in the 
sacral operation, as he has not much faith in the future use- 
fulness of these muscles, and he considers that the patient’s 
* Bei.trage kl. Chir., 1888, p. 807. 
Wien. kl. Wochemch., 1891, No. 84. 
| Zoe. cit. 
* Munch, med. Wochenschr., 1888, p. 87. 
|| Rerl. kl. Wbchensch., 1889, p. 198. EXCISION OF CANCER OF THE RECTUM. 
19 
chances are better when a large open funnel is left. Kocher 
(Arnd) also thinks it doubtful if circular suture is advisable, 
as in his experience more cures have followed complete ex- 
tirpation. Arnd in his most valuable and, elaborate paper 
has collected 24 cases of radical cure, and in 14 of these ex- 
tirpation (amputation) had been done, in 5 excision, and in 
4 resection. 
In Case IV, recorded above, by leaving the sphincter- 
attached to the skin and joining it around the rectum at a 
second operation the dangers of the circular suture were 
avoided, and, as far as functional result is concerned, its 
advantages retained. 
Relin * advises the division of the operation into two 
stages. At the first operation he frees the diseased rectum 
and, packing it around with gauze, leaves it in situ. At the 
second operation, done ten days later, he removes the diseased 
portion and sutures the two ends together. He claims for 
his method less danger of shock, less danger of infection 
and greater security for the circular suture. 
In cases of extirpation is it better to cut through the 
rectum behind and insert the finger into the gut, or to ligate 
the lower end and remove it as a closed tube ? The finger 
inside the gut may in some cases be of use as a guide, but, 
in my opinion, this advantage is more than counterbalanced 
by the danger of infection from the intestinal contents 
which are apt to escape over the wound, which is also liable 
to be infected by the contaminated finger and hand. 
How shall infection be avoided after operation ? One 
of the main dangers in this operation lies in the escape of 
faecal matter into the cellular tissue of the pelvis, resulting- 
in a phlegmon which, in many cases, has ended fatally. Espe- 
cially is this apt to be the case after circular suture. How 
can wre avoid "he possibility of this infection ? To obviate 
* Arch. f. kl. 01 dr., 1891, p. 317. 20 
EXCISION OF CAXCEK OF THE RECTUM. 
this danger various plans have been proposed. Disinfec- 
tion of the intestinal contents by drugs, such as naphthol, 
etc., has been tried, but without success. The most rational 
proposal, and one which in the hands of some surgeons 
has given satisfactory results, is the performance of a pre- 
liminary colotomy. By this plan the intestinal contents 
escape before they reach the rectum, or at least the greater 
portion finds exit at the opening in the loin. The disad- 
vantages are that two additional operations are imposed on 
the patient, for the artificial anus must afterward be closed. 
Are the advantages to he gained equal to the additional 
risk of these two operations ? In extirpation I certainly 
think not, and I do not consider in such cases that a coloto- 
my is at all necessary, provided the gut is sutured to the 
skin. The space around the rectum can be sufficiently 
packed with gauze to prevent infection in the great majority 
of cases. On the other hand, where resection and circular 
suture have been done, it seems to me a very proper pro- 
cedure. In the greater number of these cases the passage 
of faeces through the rectum has caused leakage, and has 
often resulted in infection of the cellular tissue. If the 
preliminary colotomy will prevent this occurrence it will 
certainly be a great gain. I do not feel that there is suffi- 
cient experience as yet to decide this point. The colotomy 
may he made either in the right or left inguinal region. If 
the descending colon be attached to the abdominal wall it 
is apt to interfere with the necessary descent of the gut at 
the time of the radical operation, whereas if the ascending 
colon be attached, a certain amount of faecal matter will be 
liable to still find its way down through the rectum. Apart 
from the necessity of two additional operations, this pro- 
cedure is therefore not without its disadvantages. 
As has been stated in many cases, radical operation is 
not to he considered. When the cancer is so adherent to EXCISION OF CANCER OF THE REOTUM. 
21 
surrounding parts that it will be impossible to completely 
remove it, then we must be content with palliative proced- 
ures. In cases, however, where we feel that there is a 
reasonable prospect that we can remove all the disease, 
what are the facts and reasons which should influence us in 
our decision between colotomy and excision ? There can 
be no doubt but that colotomy is the safer operation of the 
two, so far as the death rate is concerned, and were there 
in either case no prospects of cure or of long immunity 
from disease, then beyond question it should always be 
preferred to excision. Such, however, is not the case. On 
the one side stands an operation which, while affording no 
chance of permanent cure, prolongs life and makes that life 
a comparatively comfortable one. On the other side stands 
an operation which, while attended by gi eater danger, offers 
on the average a greater prolongation of life and perhaps 
less suffering, and in a few cases effects a permanent cure. 
The mortality of the radical operation is considerable— 
about twenty per cent.—but are we not justified in taking 
this larg3 risk when we consider the disease which we seek 
to defeat ? We are not dealing with a benign disease, but 
with one which can end only in a terrible death. Were the 
prospects of cure even less than they are, it seems to me 
that we would still be justified in performing the radical 
operation, for many patients have been given years of a 
comfortable existence before the relapse comes, and, even 
after the disease returns, the suffering is less intense than it 
would have been had the original trouble in the rectum 
been left undisturbed. 
The premises on which this comparison is based are : 
(«) Excision is the more dangerous operation ; (6) excision 
radically cures a certain number of cases ; (c) excision af- 
fords greater prolongation of life; (d) excision may be re- 
peated a second and third time and yet result in cure; (e) 22 
EXCISION OF CANCER OF THE RECTUM. 
excision affords greater relief to the patient even when 
relapse occurs. 
Are these premises correct ? 
First, the mortality. Different operators report as fol- 
lows : 
REPORTER. 
OPERATOR. 
REFERENCE. 
1 Number of 
| operations. 
«• 
Q 
Mortality. 
bo • 
.9 S . 
•d 2 
E a. 9 
8 g* 
a S 
Hildebrand... 
GOttingen 1 
T)eut. Zeitsch. f. Chir., 
clinic f 
Bd. xxvii, p. 329 
57 
20 
35 
24-5 
Arnd 
Kocher’s 1 
Deut. Zeitsch. f. Chir., 
clinic ( 
Bd. xxxii, p. 1 
35 
10 
28'5 
14 29 
KOnig 
KOnig 
Cenlralbl.f. Chir.,Beilage 
24, 1888 
60 
14 
24 
Bardenheuer.. 
Bardenheuer. 
Centralbl. f. Chir., Beilage 
24, 1888 
13 
2 
15-5 
Kttster 
Kiister 
Berl Min. Wochenschr., 
1889, p. 193 
16 
2 
12-5 
Billroth 
Billroth 
Wien. Min. Wochenschr., 
1891, No. 31 
13 
2 
15'5 
schweiz. Aerzte", Jan. 
15, 188 i 
21 
2 
9'5 
p. 65 
9 
2 
222 
p. 317 
7 
3 
42'8 
Arad 
Genzmer 
Dent. Zeitsch. f. Chir.. 
Bd. xxxii, p. 1 
17 
4 
23'3 
11-6 
Bd. xxxii, p. 1 
10 
4 
40 
Y. Wahl 
Bd. xxxii, p. 1 
18 
3 
16-5 
11-11 
Bd. xxxii, p. i 
25 
1 
4 
Schwider 
Bergmann... 
46 
5 
11-3 
6-25 
Hochenegg... 
Albert 
Thorndyke, in Host. Med. 
and Surq. Jour., vol. 
cxxix, p. 453 
55 
6 
10'9 
Cripps 
Cripps 
Brit. Med. Jour., 1889, 
Oct. 12 
30 
2 
7 
Kelsey 
Kelsey 
Stricture of the Rectum, 
second edition, p. 47 
7 
2 
28'5 
439 
84 
19-1 
The number of operations recorded above is 439, with 
84 deaths, which gives a mortality of 19T per cent. No 
attempt has been made to collect all reported cases, but the 
results of several prominent operators, who have reported a 
series of cases, have been simply tabulated. Arnd collected 
230 cases of operation, and estimated the mortality at 12T7 EXCISION OF CANCER OF THE RECTUM. 
23 
per cent. Welhaminow, from 335 cases, gives a mortality 
of 20-5 per cent. Esmarch estimates it at 20 per cent.; 
Konig, at 16 per cent. ; Bardenheuer, at 10 per cent. 
Thorndyke computes the mortality in 88 operations by the 
sacral method at 14-7 per cent. ; Iversen,* in 80 cases by 
the same method, at 25 per cent. The difference in these 
estimates is caused by the diversity of method of different 
reporters, some of whom reckon only such deaths as are 
caused by shock, while others include all deaths which are 
due directly or indirectly to the operation. The death-rate 
of English operators is somewhat less than that of German 
surgeons; but this is due to the fact that the English are 
much more conservative in their selection of operative cases. 
Thus Cripps states that only from 15 to 20 per cent, of 
cases are suitable for operation, while among German sur- 
geons about 75 per cent, of all cases submit to radical oper- 
ation. 
It is difficult to compare this death-rate with that of 
colotoiny, because the cases on which this latter operation 
is performed are, as a rule, in a much more desperate con- 
dition. The mortality, however, in cases of an equal gravi- 
ty can not he more than half as great as that of the radical 
operation. 
Second. Is a permanent cure effected, and, if so, in 
what proportion of cases ? It is difficult to affirm that a 
patient is cured after operation for cancer in anv organ. 
The period of exemption may be a long one. Most writers 
consider that immunity for three or four years makes the 
probability of a relapse so small that the great majority of 
such cases may be declared as permanently cured. If we 
take a period of four years after operation as our standard, 
how many patients do we ffnd perfectly free from disease 
at this time ? 
* Tram, of the Internat. Med. Congress, Berlin, 1890. 24 
EXCI8I0N OF CANCER OF THE RECTUM. 
Kocher reports 9 cases out of 35 operations. 
Bardenheuer “ 3 “ “ 45 “ 
Hildebrand “ 3 “ “ 57 “ 
Czerny “ 3 “ “ 45 “ 
Konig “ 3 “ “ 60 “ 
Kronlein “ 3 “ “ 22 “ 
V. Wahl “ 2 “ “ 18 
Von Bergmann “ 8 “ “ 46 “ 
Genzmer “ 1 “ “ 17 “ 
Cripps “ 2 “ “ 30 “ 
Total 82 cases out of 875 operations. 
This means that out of 875 patients operated on by ex- 
cision, 82 were perfectly well at the end of four years. In 
almost all of these cases the diagnosis had been confirmed 
by the microscope. This proportion of permanent cures 
is comparatively correct. While a few of these patients 
may at a later period suffer from a relapse, yet out of 
these 875 cases a certain additional number will he cured, 
for many have not been operated on as long as four 
years ago, and therefore, while quite well at the time of 
report, could not be included in the number of cured. 
These will certainly equal, and probably exceed, the num- 
ber of patients relapsing after the expiration of four years, 
so we may consider the figure of It per cent, as approxi- 
mately correct. While this is not so favorable a result as 
is obtained after excision of the mamma or uterus, yet it 
certainly gives us some encouragement to persevere in our 
efforts to perfect the radical operation. 
Many of the cases reported as cured were alive and well 
long after the expiration of four years. Kocher has five 
patients who were perfectly well more than nine years after 
operation, one having lived sixteen years and a half. 
Czerny reports a case perfectly well at the end of twelve EXCISION' OF CANCER OF THE RECTUM. 
25 
years after operation when lie excised more than live 
inches of the rectum. We may, therefore, say that our 
second premise is correct. 
Third. Excision affords greater prolongation of life 
than does colotomy in cases where relapse occurs. Arnd 
reports from Kocher’s 35 cases 4 patients who lived more 
than three years, 2 of them having lived more than live 
years. Hildebrand reports out of 57 operations 2 patients 
alive after four years, and 5 alive after two years. Konig 
reports 4 cases alive after three years. Volkmann reports 5 
cases alive after three years. Almost every operator re- 
ports a certain number of patients who live from three to 
live years after operation and then die from a relapse. 
Stierlin has reckoned the average duration of life after the 
radical operation as 43 months, after colotomy 28’S months. 
This is a longer life than is usually granted by most 
surgeons. 
Fourth. A cure may yet result even where for repeated 
relapses a second and third operation has been performed 
on the same patient. A typical excision has been done, a 
relapse occurs; after several months’ interval a second 
operation is done, followed by a third relapse and third 
operation, and yet a cure finally results. Thus Arnd re- 
ports a patient who had four relapses and five operations, 
and who was well at the end of thirty-nine months after his 
last operation (ninety-one months after the first excision). 
Turner, Volkmann, and Sihle have each reported a patient 
where, after three operations (two for relapses), permanent 
cure resulted. These and other writers have reported a 
number of cases where, after the second operation, for 
return of the growth, cure has resulted, as proved by the 
good health of the patients at the expiration of from five 
to eight years. 
Fifth. Excision affords greater relief than does coloto- 26 
EXCISION OF CANCER OF THE RECTUM. 
my in cases where the cancer returns. The recurrence is 
generally external to the rectum, in the glands and cellular 
tissue of the pelvis, and therefore ulceration of the mucous 
membrane is less liable to occur and constriction of the 
caliber of the gut is less apt to result. More than this, 
many nerves must have been divided at the original opera- 
tion, and, in consequence, the tissues are less sensitive than 
they otherwise would have been. 
One point remains to be considered, and it is difficult 
to form any definite conclusions in regard to it: Are the 
functional results after excision better than after colotomy ? 
What is the local condition as regards function in those 
patients whose rectum has been excised ? What control do 
they have over the bowel movements ? Have they abso- 
lute control (continence), or only partial control (relative 
continence), or is all control absent (incontinence), or does 
a stenosis exist ? 
Hildebrand * followed 4 cases of extirpation ; there was 
incontinence in 3, stenosis in 1. Konigf has been able to 
follow 21 cases after operation; of these, 6 had so much 
control over their bowels that they were not annoyed by in- 
continence ; 15 had so little control that they were made 
uncomfortable by the incontinence. Out of 4 cases of ex- 
tirpation, there was complete incontinence in 3, stenosis in 
1. In 17 cases of resection there was complete continence 
in 6, incomplete continence in 9, and stenosis in 2. 
Out of 36 cases operated on by Cripps, \ in only 7 was 
there incontinence, while in 6 there was relative continence, 
and in the remainder (23) there was complete continence. 
It may be stated, T think, as regards functional results, 
that, while the anus is situated in the natural position, yet 
* Loc. tit. 
I Loc. tit. 
% Butlin. Surg. Malignant Dis., p. 245. EXCISION OF CANCER OF THE RECTUM. 
27 
the control over the rectum is no better than is obtained 
after colotomy. 
While many of the assertions which have been made in 
the above article, especially as to the operative technique, 
are largely matters of opinion, yet I think the following 
conclusions can be reached and are approximately correct: 
1. The mortality of the operation is about nineteen per 
cent. 
2. Cases can be successfully operated on when the dis- 
ease extends higher than the peritoneal attachment. 
3. Certain patients are permanently cured, probably 
about eleven per cent, of all cases operated on. 
4. In patients who have a recurrence of the disease, ex- 
cision gives a longer life and a more comfortable one than 
does colotomy. REASONS WHY 
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