CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 15)

ed. 1879. 16 242 DISEASES OV THE BECTUM AND AKUS. an epithelioma the size of a hen's egg, situated on the posterior wall of the rectum an inch above the sphincter, with considerable surrounding infiltration. The spliincter was stretched, and the mass seized with a double tenaculum, and drawn well down by an assistant. 'A steel grooved director, as the most convenient instrument for the purpose, was pushed through the skin in front of the coccyx and just behind the outer edge of the sphincter, into the cellular tissue of the pelvis, and then made to puncture the rectum, in healthy tissue, just beyond the upper edge of the tumor. The end was turned out of the gut, and pushed far enough forward to rest on the perineum while the other end was over the coccyx. Then a second director was pushed around from the outer side of the muscle on one side, through the cellular tissue into the rectum, across to the other side, through the cellular tissue and skin again to the opposite side of the muscle. So that the mass, with a portion of the rectum above, was now brought through the anus and fixed by the two directors, which had been passed behind the mass at right angles to each other, with their ends resting outside on the soft parts. The chain of an 6craseur was placed behind these two instruments and slowly tightened till the whole mass, as transfixed, was cut through along the course of the directors. By this means, I removed the entire sphincter muscle, about three inches of the posterior wall of the rectum, and about an inch and a half of the rectal surface of the recto-vaginal septum. The immedi- ate result was a most formidable opening in the connective tissue of the pelvis, about three inches in diameter and cone-shaped from below." Dr. Bouse* has recently called attention to a simple method of avoiding a wound of the sphincter, which is applicable to some of the slighter cases. A curved incision is made parallel with the outer border of the sphincter, and on a line with its outer limit. By introducing the finger through the rectum, the growth may be everted through this incision, and removed with the part of the rectal wall to which it is ad- herent. Perhaps the best of all the operations we have spoken of is the com- bination of the 6craseur and galvano-cautery knife, as used by Ver- neuil. But the operator is at liberty to choose from among them all the one he considers easiest of performance, and most free from the risk of hsBmorrhage or of wounding surrounding parts. A wound into the vagina, though always to be avoided when possible, may often be necessary in order fully to remove the disease. When the fistula thus made is not too extensive, it may be closed immediately after the operation. If large, it must be left. A wound of the urethra in the male, when slight, is to be treated as though the patient had submitted to an external urethrotomy, by the frequent passage of the sound, to pre- vent contraction. "When a large piece has been taken from the urethral > 1 Lancet, Oct 2d, 1860. CANCER. 243 wall, a permanent recto-urethral fistula is the necessary result, and the danger of fatal inflammatory action is greatly increased from the presence of the urine in the rectal wound. As for the cases reported by K"ussbaum and others, in which the whole neck of the bladder, the gi-eater part of the prostate, and the seminal vesicles have been removed, and the patients have lived for years in comfort, they are merely curiosi- ties of literature. That such a thing may happen has been proved, but that the operation should ever be undertaken in any case where such a result is necessary for the entire removal of the disease, has yet to be proved. It is with this operation much the same as with proctotomy — by try- ing to save too much, discharge is impeded and life may be lost. Cases where the whole of the sphincter is removed, together with the skin of the anus, do better than those in which an attempt is made to save the sphincter and drain the wound with drainage-tubes. The operation of excision has, with the recent advances in abdominal surgery, also been applied to cancer of the sigmoid flexure and descend- ing colon. This operation to which allusion has already been made and to which Mr. Marshall* has very properly applied the name of " colec- tomy " has now assumed a definite place in surgery and marks another of the great advances of the present century. It dates from the time of Beybard of Lyons," who in 1833 removed a tumor the size of an orange from the sigmoid flexure of a man aged twenty-eight years. In this case the tumor could be felt through the ab- dominal wall in the left iliac fossa, and the incision was made parallel with Poupart's ligament and the crest of the ilium. The tumor was drawn oat through this wound and excised with three inches of the ad- joining intestine. The two ends of the bowel were stitched together and replaced within the abdomen and the abdominal wound was completely closed. There was considerable local trouble for a few days, but on the thirty-eighth day the wound had entirely healed and the natural pas- sages were restored. Death occurred ten months after from recurrence of the disease. This case was subject to considerable discussion in the academy, but was finally admitted as authentic. The operation thus inaugurated in 1833 has been modified in two essential particulars by subsequent operators, one in the choice of loca- tion of the incision, the other in the subsequent disposal of the ends of the divided intestine. Since the first case by Keybard, the operation has « been performed at least seven times. Gussenbauer, of Lidge, has done it twice. The first time in 1877' was upon a male patient aged forty-two years. The tumor which was asso- ^ Clinical Lecture on Colectomy, Lancet, May 6th, 18th, 1882. « Bull, de TAcad. de Med., vol. ix., 1843-4. ^ Arch. fi!irklin. Chirurg., Bd. xxiii., 1879. 244 DI8EA.SES OF THB BBCTUM AND ANUS. ciatcd with the usual symptoms of obstruction could be felt in the left sidcy but an attempt was made to remove it through an incision in the median line of the abdomen. This incision proving insufficient, was en- larged by cutting laterally as far as the lumbar fascia. Another compli- cation arose from the attachment of the growth to the small intestino which was opened, and faBces were allowed to escape into the peritoneal cavity. All the intestinal wounds were closed with sutures, the bowel was replaced within the abdomen, and the abdominal incision sewed up. In this case death followed in fifteen hours. Qussenbauer's second case was performed in 1879,' and there had been no return of the disease two years later. Baum of Dantzic* operated between these two dates (1878) upon a male patient, aged thirty-four years, in a case of doubtful nature. He first opened the small intestine to relieve the symptoms of obstruction, and seven days later he discovered the seat of the obstruction in the right hypochondrium. A second operation was then performed. The abdo- men was again opened, this timq by a longitudinal incision over the tumor, two and a half inches to the right of the median line, and this incision was afterwards enlarged by another running toward the right. The growth was situated at the junction of the transverse with the as- cending colon, and was removed together with a piece of the mesentery which contained an enlarged gland. The divided ends of the bowel were invaginated and united, the intestine replaced, and the abdominal wound closed. There was considerable discharge of faeces from this opening, however, up to the time of death on the ninth day. The next case was by Martini, of Hamburg,'* in 1879, and was per- formed with the deliberation and consequent success which arii^e from a certainty in diagnosis of the character and location of the tumor. The growth was situated in the sigmoid flexure and could be felt both through the abdominal wall and the rectum. The incision was made over the tumor, the intestine below was cut between double ligatures, the meso- colon was divided and the affected glands excised, and finally four inches of the bowel were excised together with the diseased mass and two inches breadth of mesocolon. After the removal of such a section it was impos- sible to approximate the divided ends of intestine. The rectal end was, therefore, invaginated upon itself, closed with sutures and allowed to drop into the pelvis. The upper extremity was attached to the incision in the abdomen to form an artificial anus. There were no bad symptoms and in a few weeks the man was able to return to his business. Czerny, of Heidelberg, reported the next successful case in 1880,* in a 1 Ztschr. fQr Heilk., Prag, 1880. » Centralblatt fur Chir., 1879, Bd. ii., p. 169. 3 Vierteljahrschrift fOr Heilk., Bd. i., 1880. * BerUner klin. Woch., 1880, No. 45. GAKOER. 245 female patient, aged forty-seven years. In this case also the growth could be felt through the abdominal wall on the left side and the diag- nosis was therefore positive. After opening the abdomen over the tumor, the bowel was found to be implicated at two points, one at the transverse colon, and the other at the sigmoid flexure which curved upward to an •abnormal degree and was involved in the same disease through a fol4 of the great omentum. Two and three-quarters inches of the sigmoid flexure, and four inches and a half of the transverse colon were excised and the cut ends of each portion were united. The peritoneum was washed out, a drainage tube inserted, the abdominal incision closed ex- cept for the drainage tube, and the whole dressed antiseptically. For a time there was a discharge of faeces through the abdominal wound, but this finally closed and the patient was well in four months. The return of the disease was, however, very rapid, and death was caused by it in about seven months after the operation. Billroth operated next in order, in 1881,^ on a male patient twenty- eight years of age. The operation was done antiseptically, and the inci- sion was the usual one for left inguinal colotomy. The tumor involved the lower half of the sigmoid flexure, and there was considerable involve- ment of the adjacent mesentery and of the tissue behind the bowel. The upper section of the bowel was used for the formation of an artificial anus. The patient died in about thirty-six hours from incipient diffuse peritonitis. Bryant's case * is next in order, and is peculiar in the fact that the in- cision was the usual one for left lumbar colotomy. This, in fact, was the operation attempted, but after the bowel had been opened, the obstruc- tion was found to be above the opening made. It was then determined to excise the disease, and this was successfully done through the original incision. The two ends of the bowel were attached to the wound, the upper in the usual manner for forming an artificial anus. The patient recovered, and was well at the time of the publication of the case. The disease constituted a cylindrical stricture of limited extent. Fmally, Mr. Marshall's ' case has just been published at the time of writing. The patient was a woman, aged forty-nine years, and no posi- tive diagnosis as to the seat of the obstruction could be made. The difi&- culties attending the diagnosis may best be gathered from his own descrip- tion, ^' The wasting and rapid ageing of the patient, although she took food tolerably well, suggested the presence of a malignant stricture, probably epitheliomatous; but it was difficult to say how far the symptoms were referable merely to the pain and vomiting which she had suffered; but, > Wien. Med. Woch., March 5th, 1881. 'Lancet, Vol. i., 1882. » Lancet, May Cth, 18th, 1882. 246 DISEASES OF THE BECTUM AND ANUS. whatever the nature of the obstruction^ its seat was obscure. The chro-> nicity of the casQ pointed strongly to the large intestine, but the abdomen, was not broad in shape; no tumor or scybala could be felt in either iliac fossa^ or elsewhere along the course of the large gut, though both fossae could be well examined under chloroform. There was no dulness in either loin to indicate a full colon, and no '^ colonic" note to show thai the bowel contained gas. Rectal examination revealed nothing. The long tube passed one foot, and an enema of three pints was easily given> and seemed, from an accompanying diminution of resonance in the left flank, to have entered the descending colon. But as the patient was lying- on the left side, it was possible that fluid contents had gravitated into the small intestines lying over the descending colon — a source of movable dulness which, as remarked by Mr. Boyd, is often overlooked. The amount and uniformity of the abdominal distention were sufficient to- prove that the obstruction, if in the small intestine, was near the lower end. If, however, the suspicion were correct that the cause of the ob- struction was an epithelioma, the probability of its seat being in the large intestine, somewhere beyond the csBcum, was greatly increased." On account of the uncertainty in diagnosis, the incision in this case was an exploratory one in the median line, and the growth was found in the descending colon, between the lower end of the kidney and the iliac crest. As it was impossible to bring this part of the bowel to the median line, the first incision was abandoned, and a second one made over the tumor, parallel with the last rib, and one inch and a half above the poste- rior part of the iliac crest. The growth was cut out with the scissors, together with an inch of the bowel above and below, between double lig- atures. The open end of the upper section of the bowel was attached to the abdominal wound to form an artificial anus, and the lower end waa left projecting from the lower and hinder part of the wound with the strong catgut ligature drawn tight upon it. The patient died of perito- nitis on the third day. Of these eight cases, oncrhalf may fairly be said to have prolonged life, and the others have been fatal within a short time from peritonitis. As pointed out by Marshall in his instructive resume of the operation, the result undoubtedly depends in a great degree upon the certainty with which the diagnosis is made, or, in other words, upon the exact adapta- tion of the operation to the end to be attained. In most of the successful cases, the diagnosis as to the seat of the obstruction was made before the operation was begun, and in all of them only a single incision was neces- sary to reach the tumor. In three of the four fatal cases, two incisions were made — one in the median line, and, subsequently, another to reach the disease. In this way the severity of the procedure was greatly in- creased. There seems to be little difference in the mortality whether the ends of the divided intestine be united and the abdominal wound closed; or CANCER. 247 one end be brought to the surface for the formation of an artificial anus. The latter is the simpler procedure; the former, when, successful, gives the better result. A great difference in the size of the two ends will some- times render their union difficult; the upper one being frequently hyper- tvphied and dilated, and the lower contracted. The study of these cases leads plainly to the following conclusions: — 1. In cancer of the descending colon, sigmoid flexure, and upper part of the rectum, when the disease is still movable, an attempt at its re- moval through the abdominal wall is justifiable. * 2. In cases of obstruction where the symptoms point toward this part of the bowel as the affected part, even when the diagnosis is not certain, it may be well to make the exploratory incision in the left groin instead of in the median line, having in mind the possible extirpation of the dis- ease and the formation of an artificial anus. 3. In cases of intended colotomy also, it may be found possible, after the incision has been made, to substitute colectomy, and this constitutes another reason for choosing the inguinal to the lumbar incision in that operation, though, as in Bryant's case, colectomy may be done through the loin. 4. The operation of colectomy compares very favorably with colotomy in malignant disease, and while the latter may be the more suitable in an advanced case, the former may give better results when the disease is in its incipiency. The palliative treatment of malignant stricture of the rectum is in many points the same as of non-malignant. The relief of pain is perhaps a more marked indication in most cases. The pain depends on two classes of causes — those which make cancer a painful disease wherever met with in the body, and those which are due solely to its situation at the outlet of the bowel. Among the first, we have pressure upon adja- cent parts and involvement of neighboring organs and nerves; and among the second, the passage of faeces over an ulcerated surface and spasm of the sphincter muscle from irritation caused by its direct implication in the cancerous growth, or by the passage over it of irritating sanious dis- oharges from the sore. From this