[Reprinted from The Medical News, July 20, 1895.] 
EXTIRPATION AND COLOTOMY IN CASES OF 
CARCINOMA OF THE RECTUM.1 
By LEWIS H. ADLER, Jr., M.D.; 
PROFESSOR OF DISEASES OF THE RECWM^PHILADELPHIA POLYCLINIC AND 
COLLEGE FOR GRADUATES IN MEDICINE ; SURGEON TO THE CHARITY 
HOSPITAL AND TO THE OUT-PATIENT DEPARTMENT OF THE 
EPISCOPAL HOSPITAL, PHILADELPHIA. 
Colotomy and extirpation are two recognized 
procedures for the relief of malignant disease of 
the rectum. Both operations offer the patient a 
chance of prolonging life ; and, in addition, extir- 
pation holds out the possibility, in selected cases, 
of effecting a radical cure. 
The choice between these two methods is a ques- 
tion of uncertainty only in a relatively small group 
of cases. Extirpation is not to be considered in 
the majority of instances, for the reason that the 
disease is usually an incurable one, and, by virtue 
of its concealed position within the rectum, its 
presence is not revealed or even suspected until the 
growth has existed for some time. Furthermore, it 
is rare for carcinoma of the rectum in its incipiency 
to manifest itself by any symptom pointing to a 
lesion within the bowel. This is a familiar obser- 
vation to all surgeons. 
It frequently happens that a patient comes com- 
plaining of slight diarrhea or other mild rectal 
trouble, and an examination unexpectedly reveals 
1 Read before the Surgical Section of the American Medical 
Association at Baltimore, Md., May, 1895. 2 
the fact that carcinoma is present to such an extent 
that it is obvious that the neoplasm has existed for 
a considerable period. Consequently its complete 
removal is often rendered impossible. Again, the 
patient's vitality is such that so grave an operation 
as excision, requiring considerable time for its per- 
formance, is contra-indicated. 
In arguing thus I would not convey an impres- 
sion that I am opposed to extirpation for malignant 
disease of the rectum in suitable cases. On the 
contrary, I firmly believe it to be a perfectly justi- 
fiable operation when the growth is circumscribed 
and confined to the lower four or five inches of the 
bowel; provided, however, that the tumor does not 
involve all the coats of the intestine, that it has not 
attacked the viscera which are intimately associated 
with the anterior wall of the rectum, that it has not 
invaded the pelvic glands or, by metastasis, any of 
the other organs of the body, and, finally, that its 
growth be not rapid or have a tendency to spread 
widely. From these considerations it naturally 
follows that the number of patients who can be 
benefitted by excision of the disease is comparatively 
small. 
Colotomy, on the other hand, is indicated in a 
large number of instances in which it is quite im- 
practicable to attempt an excision. The advantages 
of the operation lie partly in the relief it affords to 
symptoms and partly as a means of retarding the 
growth of the neoplasm. 
To indicate the relief afforded such patients by 
colotomy I cannot do better than quote the opin- 
ion of Kelsey on the subject, as expressed in the 
fourth edition of his work, Diseases of the Rec- 
tum and Anus.x This authority is not only a 3 
strong advocate of the operation, but is also in a 
position to judge of its merits by reason of his 
large experience. He thus states his views : 
"As to the benefits arising from the operation 
too much can scarcely be said. That it prolongs 
life by the relief of pain, the preventing of obstruc- 
tion, and retarding the growth of cancerous disease, 
is beyond question. That it substitutes in many 
cases a painless death for one of great agony is 
indisputable. The idea that it is as well to let a 
patient die as to subject him to a colotomy has no 
supporters among surgeons who have had any ex- 
perience with these cases. Indeed, I think that the 
practitioner who to-day sat by and allowed a patient 
to die of obstruction because of any sentiment 
against this procedure would hardly be held blame- 
less. I can only say that, after trying every other 
means of treatment and being obliged to admit the 
fruitlessness of them all, I have come, with most 
others, to admit the great benefits of colotomy, and 
have never performed it in any case in which either 
the patient or myself has afterward regretted it.'' 
(Italics mine.) 
In another article Kelsey1 mentions even more 
minutely the advantages of this operation, as fol- 
lows : 
"Colotomy, especially inguinal colotomy, re- 
lieves pain; does away with the constant tenes- 
mus and discharge from the rectum, which, by 
their exhausting effects are the immediate cause of 
death; delays the development of the disease by 
preventing the straining and congestion of defeca- 
tion ; prevents absolutely the complication of in- 
testinal obstruction, which is another cause of 
death; enables the patient to sleep, eat, and gain 
flesh, and often makes him think himself cured in 
1 Pp. 409 and 410. 4 
spite of the plainest prognosis to the contrary. 
Instead of passing his days and nights upon the 
commode, wearing out his life in the effort to free 
the bowel from the irritation, he has one or, per- 
haps, two solid fecal evacuations from the groin in 
twenty-four hours." 
In conclusion, I would allude to one more topic, 
to wit: The choice of sites of opening the colon. 
I mention this subject with the sole purpose of elic- 
iting the present views of the members of this 
society. My own belief is that the inguinal region 
is to be preferred in the majority of cases. Its 
advantages over the lumbar operation are, to my 
mind: 
1. The smaller incision and lesser depth of the 
wound requisite to reach the colon, and the mini- 
mum amount of disturbance of the structures over- 
lying the seat of operation. 
2. The greater facility offered for the exploration 
of the abdomen, when such a procedure is required. 
3. The better position for safe anesthesia during 
the operation. 
4. The comparative ease with which the colon 
may be identified in this position and the little 
difficulty experienced in fixing the bowel to the 
skin without undue tension on the stitches. 
5. The greater readiness with which a good spur 
may be formed. 
6. The convenience to the patient of the site, for 
purposes of cleanliness and for the adjustment of 
pads; and 
7. Recent statistics seem to indicate that it is 
the less dangerous operation. 
1610 Arch Street. 
1 New York Medical Journal, November, 1892.