CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 10)

high for extirpation; ulceration; loss of flesh and strength; great pain on defecation; retention. Sphincter divided with chain on left side in such a way as not to involve the cancer. One year later, freedom from pain; general state good; incontinence following opera- tion disappeared; difficulty in passage of solids overcome by seltzer; gradual advancement of cachexia. — Gaz: Hebdom., Mar. 27th, 1874, p. 196. 6. Vebneuil. — Cancer high up, involving prostate and vesiculae seminales. Continued diarrhoea and incontinence, and bad general con- dition. A double posterior external operation was done with the chain, and the portion included between the two incisions cut away, with the idea of relieving pain and retention and opening a passage for tlie subse- quent application of escharotics to the cancer. Operation followed by immediate relief of worst symptoms. — Gaz. Hebdom., March 27th, 1874. 7. Nelaton. — Operation done with bistoury. Relief continued till death, eighteen months after, from extension of malignant disease to the pelvis. — Panas, Gaz. des Hop., 1872, p. 1,149. 8. FocHiER. — Cancer of posterior part of rectum, reaching to height of ten centimetres. Qreat pain and tenesmus; foetid and bloody dis- charge; loss of sleep. Complete division with ecraseur. Left hospital ten days after, believing himself cured. After two months, had no more pain and no incontinence, except when suffering with diarrhoea. Had two regular passages daiily, and complained only of not regaining his strength. In this case, the section extended to the unusual height of twelve centimetres from the anus. — Lyon Med., Feb. 20th, 1876. I have performed this operation in various other cases, and have every reason to be satisfied with its results. In malignant or non-malignant stricture and ulceration, I have never seen it fail to give immediate relief to suffering, and, as a means of relieving the pain of the disease, I believe NON-MALIGNANT BTRIOTUBU OF THE RBOTUM. 213 it to be fully equal to colotomy. It also fulfils the other great indication for colotomy, the overcoming and prevention of obstruction. Too much must not be expected of the operation, however. I have seen several cases, one in my own practice, and several where I have ad- vised the operation in consultation with others, which have led to disap- pointment for this very reason. An old stricture of the rectum with extensive ulceration is a well-nigh incurable disease. Proctotomy may be relied upon with certainty to relieve the pain and prevent faecal obstruc- tion even in the worst cases, and in more favorable ones it may effect a practical cure by opening the canal, causing a diminution in the indura* ion, and allowing the ulceration to heal, but it will not cure them all. Nothing at present known to surgery will. A rectum which has once been diseased to this extent is never again a healthy one, though it may be made a very comfortable one. Another point which must not be overlooked is, that, after proctotomy as after colotomy, there is still a diseased rectum which must be treated by every possible means; and that the incision may be only the first step in the cure. The stricture is easier to overcome than the ulceration which accompanies it. In the case given above, I succeeded ultimately by long and patient effort in curing that also, but it cannot be done in every case. In many of these cases the ulceration must be treated as ulceration with the same results, both good and bad, as usually attend the treatment of that most painful, obstinate, and often incurable condi- tion. But the chances of curing it, and at all events of relieving it^are infinitely better after the operation than before. It is understood that I do not advocate the operation in cases of dis- ease high up in the bowel, though it may be safely done at a considerable distance from the anus, and where an incision involving the anterior wall would be unjustifiable, for the anatomical reason that the peritoneum extends so much lower in front than behind. For other literature upon this subject, the reader is referred to the bibliography given below. BiBLIOGBAPHY. Panas: Du traitement des rStr^cissements du rectum par la rectotomie externa^ Oaz. des H6p., December, 1872, p. 1,148. Muron, A.: Des r^trecissements de rextr6mit6 inferieure du rectum, et de leur gu6ri8on par la rectotomie lineaire. Oaz. M6d. de Paris, January 4th, 1878. Fochier, A. : Sur Tapplication de la rectotomie lineaire aux retr^cissements tres-^tendus du rectum. Lyon Medicale, February 20th, 1876. Pinguet: Des retr6cissements du rectum; appreciation des di verses m^thodes th^rapeutiques. Th^ de Paris, 1878, No. 17. Tison: Nouvelles consid6rations sur la rectotomie lineaire. Thdse de Paris, 1877. Torgis: Foreign Body in Rectum. Bull, de la Soc. de Chir., tome iv., No. 10, 1878, p. 789. Cerou: Th^se de Paris, 1875, No. 890. 214 DIBBA6B8 OF THE BECTITM AND ANUS. Whitehead, W. B. : Case of Fibrous Stricture of the Rectum Relieved by In- cisions and Elastic Pressure, with Remarks. Amer. Jour. Med. Sc., January, 1871. Whittle, G. : Stricture of the Rectum Divided by the Knife. Lancet, June Ist, 1879, p. 788. Lente, F. D. : Report of a Case of Non-Malignant Stricture of the Rectum, and Remarks on the Surgical Treatment of this Disease. Amer. Jour. Med. Sc.,. July. 1873. Beane, F. D.: Case of Specific Stricture of the Rectum; Antero-Posterior Linear Rectotomy; Recovery; Remarks on the Operation. Amer. Jour. Med» Sc., April, 1878. Discussion sur les r6tr6cissements du rectum. Bull, de la Soc. de Chir., Paris. 1878, p. 88. Vemeuil, et cd.: Rectotomie et colotomie (Soc. de Chir., Paris). Prog. Med., January 7th, 1882. Excision. — The operation of excision, which is generally applied only to cancerous strictures and which will, be fully described under that head, has also been applied to simple strictures; and, though I have never done it myself, I have seen a few cases which seemed particularly adapted ta it. One such case is reported by Dr. Lowson * in which the result was comparatively good, though no better than that obtained by proctotomy. The operation performed by him consisted in dividing the external sphincter posteriorly, so as to arrive at the stricture, pulling it down through this wound when possible, dividing the bowel above and below it, ^ssecting it out from its attachments, and uniting the two ends of the bowel by sutures. In this case there was considerable difficulty in the subsequent union of the parts, and after healing had occurred, there was considerable contraction, but the condition of the patient was greatly improved. • Colotomy. — This is the last resort of surgery in dealing with ulcera- tion or stricture of the rectum. In ulceration it may be a curative mea- sure; in stricture it is only palliative, and it should therefore not be undertaken till other measures have failed. It is intended to fulfil two important indications, the relief of pain, and preventing or overcoming obstruction, and we have already seen how both of these may be met in many cases by other means which, even when only partially successful, are much preferable. When none of the methods already pointed out serve to assuage the suffering, and when it is probable that the suffering is not due to an irritable sphincter muscle, or to pressure on neighboring nerves from the mass of the deposit, cancerous or otherwise (in which latter case colotomy cannot be expected to afford relief), and when none of the means already described for preventing or overcoming obstruction can be applied, colot- 1 Case of Stricture of the Rectum, treated by Excision of the Stricture. Lan- cet, April 12th, 1879. NON-MALIGNANT STRICTUBB OF THE KECTUM. 216 omy may be resorted to. There is, however, but one class of cases in which obstruction may not be overcome by attacking the stricture itself, instead of the bowel above it, and that is where the stricture is too high to be safely reached by the knife, and where, even then, dilatation is too painful or too dangerous to be admissible. Judged by these rules, colotomy would be limited to a small propor- tion of cases. It would be tried after division of the sphincter and of the stricture had each failed to give relief in disease near the anus; and practically would be limited to disease high up in the bowel. Such re- strictions as these would greatly limit the number of operations especially in the United States, and I am not sure that this might not be done with advantage. We seldom see in the reports of this operation in current literature any other reason given for its performance than the mere ex- istence of obstructive or painful disease; and yet I doubt if the mere presence of a stricture of the rectum, malignant or benign, is a justifiable reason for the performance of this repulsive and serious operation. It has yet to be proved that colotomy delays cancerous growth, though it certainly prolongs life by diminishing pain and overcoming obstruction. But the relief to the pain may be and often is only partial, for a small amount of faeces which has passed the artificial anus may cause as much suffering and tenesmus as the natural quantity. In almost direct proportion as the operations of proctotomy and of partial or complete excision of strictures have become popularized and their advantages in suitable cases have become manifest, the operatibn of colotomy has been limited and the natural objections to it, both by patient and surgeon, have been allowed more weight in influencing the treat- ment. Especially is this the case in France, the birthplace of the opera- tion, and in Germany, while England, as represented by AUingham, is plainly following in the same course. In this country alone does coloto- my still hold its sway — partly for the reason that its substitutes have never been so thoroughly tried here as on the other side of the water. It would be easy at the present time to collect a much larger table of cases of this operation than was accessible to Mason when he published his paper on this subject, but I do not know that anything would be added to our general knowledge of the subject by such a labor. AUingham had operated at the time of his last edition twenty-seven times. His best result was obtained in a man with a scirrhous growth filling up the pelvis, in whom life was prolonged four and a half years after the operation. Another case, a woman, lived nineteen months, twelve of them in won- derful comfort. Only three of his patients died within a fortnight of the operation, one from phlegmonous erysipelas, another from exhaustion; and the third, in nine days, in whom there was complete obstruction at the time of the operation; and in whom paracentesis abdominis was performed immediately after the colotomy; acute pleurisy being the immediate cause of death. Curling has performed the opera- 216 DISEASES O:^ THE BECTIJM AND ANUS. tion eighteen times with seyen fatal results; two from chloroform, one from already existing peritonitis, another from peritonitis arising inde- pendently of the operation, but immediately sucoeeding it, one from pyaemia, and two from exhaustion, one on the sixth, and the other on the twelfth day. Bryant records fifteen operations of his own, four for vesico-intestinal fistula; two for pelvic tumor; and nine for stricture, cancerous and otherwise. Of these latter, one lived eighteen months in comfort, dying at last supposably of cancer of the liver; t\Vo lived two and four months respectively; one lived thirteen days, and two three days; in these cases the operation having been undertaken too late to prolong life. One died of peritonitis due to the operation, and three were alive at periods varying from one to three years. Bulteau^ has collected one hundred and forty two cases of lumbar colotomy from the statistics of Doliger, Mason, Hawkins, and Heath. Of these ninety-two recovered and fifty died. These figures are about the same as those reached by D'Erckelens.' These figures show as well as would a more elaborate collection of cases the general results of the operation itself, the dangers which attend it, and especially the danger of postponing its performance till the patient is at the point of death. These patients sometimes sink with unexpected rapidity at the end, and when seemingly no worse than for weeks before are often very near death. In my own experience I have had a patient die in the night upon whom I intended to operate in the morning. Although an artificial anus is justly regarded as being only a substi- tute for death itself; and although many patients will deliberately choose the latter to the dangers and results of the former; it is astonishing how comfortable a patient may be with one where the retention of faeces is good. Bridge's case,' in which the prostitute followed her customary avocation after its performance, is certainly an exceptionally favorable one, but it illustrates what may be done. Still we have AUingham's* testimony that ** this operation, though doubtless it may prolong life, should not be resorted to without due consideration, because one cannot fail to see in many cases the remedy proves a most objectionable one; an opening in the left loin through which the faeces escape is very harassing and nothing but a great desire to live or the fear of immediate death would lead me to submit to such a proceeding. I presume after years the patients get used to the discomforts and loathsomeness of their condi- tion. My patients who have lived long seem to have had some pleasure in life; indeed, two women were married after the operation; but with all that I entertain repugnance to the operation greater than I formerly used, * De rocclusion intestinale au point du vue du diagnostic et du traitement. Th^se de Paris, 1878. 2 Arch. fQr Klin. Chirurg., vol. xxiii., 1 Heft, 1878. 'Loc. cit. •• Loc. cit , p. 253. NON-MALIGNANT BTBIOTUBE OF THE BECTCJM. 217 and latterly haye mostly performed it as a last resource or for total obstruction." The operation has already been described. A free discharge of faeces may follow the opening of the bowel, or there may be only a slight escape of fluid. It is better for the patient that the evacuation should be post- poned till the edges of the wound have become agglutinated, as in this way the danger of extravasation is diminished. Morphine should be given hypodermically to keep the bowels as quiet as possible till cicatriza- tion is complete. Only the simplest dressings and perfect cleanliness are necessary in the way of local treatment. The sutures may be left in till they commence to cause suppuration. If the bowels are slow to empty themselves, an enema may be administered, or a scoop used through the new opening and a purgative may be given by the mouth. No change is necessary in the ordinary diet after the second day. The patient should be kept in bed for two or three weeks till cicatrization is complete, and then a pad must be arranged to cover the new anus and prevent leakage of faeces and prolapse of the mucous membrane. Bryant says some of his patients have found great comfort from the use of an india rubber ball with one of its sides cut away sufficiently to cover the new opening. It holds any little faeces which may come away, besides preventing the escg,pe of flatus and serving as a pad. Annoying prolapse is not as apt to occur with the oblique incision as with the old vertical one, nevertheless, it may be expected in some degree, and the patient should be taught to exercise the greatest regularity in re- lieving the bowels early in the morning. Should faeces pass the artificial opening, as they are apt to do, they must be removed by enemata, for a very small quantity will cause great pain and a constant demand for their removal. It will at once be seen that the treatment of a stricture high up in the rectum or in the sigmoid flexure must be conducted on entirely differ- ent principles froin one within reach of the finger. In the latter case, the disease itself may be directly attacked with the bougie or the knife; in the former, both are nearly out of the question, and the surgeon is in reality limited to attempts at warding off the natural effects of the malady; in other words to preventing the occurrence of intestinal obstruction, and forming an artificial outlet for the contents of the bowel when obstruction is threatened. The medicinal means of pre- yenting obstruction, and of overcoming it when actually impending, have already been referred to in the chapter on prolapse and invagina- tion. In cases of cancerous disease, attention must be given to cleanliness as well after as before the operation, and this Is best secured by frequent injections of an unirritating disinfectant, as the permanganate of potash. In cases of non-malignant ulceration, the diseased surface may be treated after the operation as before. 218 DI8BA8E8 OF TUB BECTDM AND ANUS. , _ "A OHAPTEE XI. CANCER. General Characters of Malignant as Distinguished from Benign Growths. — Malig- nant, Semi-Malignant, and Benign Adenoma.— Encephaloid.^Colloid. — Melanotic Cancer. — Osteoid Cancer. — Age at which Cancer occurs. — Symp- toms. — Diagnosis. — Treatment. — Excision: History and Results of Operation. —Conclusions Regarding Excision. — Modes of Performing the Operation. — Excision of Cancer of the Sigmoid Flexure.— Palliative Treatment, In a general way it is undoubtedly true that new growths in the rec- tum, when benign, increase slowly, tend to grow away from the wall of the bowel, to form pedicles for themselves, and to project into the calibre of the canal, to remain movable, and not to involve surrounding parts; while with cancerous formations the tendency is just the opposite.