The principles and practice of modern surgery

by Roswell Park

So frequently is this the case, and so prone are many practitioners to accept such a statement, that the proper examination which should permit the recognition of the condition is perhaps not made until the patient is really in a pitiable condition. I do not recall ever having seen a case of cancer of the rectum which had not been regarded, by some physician as piles, and in most cases locally treated by him, usually without any adequate local examination, and usually also until the time had passed when a radical operation could be practised with any degree of hope. The first examination at least will be digital, and if the malignant growth be within reach of the finger it should be possible to appreciate it, to estimate its size, degree of attachment, and the amount of infiltration, as well as the extent to which it is breaking down. A soft, rapidly growing cancer will give a fungous sensation to the finger, while the more dense, scirrhous forms produce hard masses, growing in irregular shapes, sometimes involving one side of the bowel, sometimes appearing in annular form, and tending sooner or later to produce malignant destruction. The only difficulty would be in cases seen exceptionally early or in those beyond reach. The circumstances above detailed should lead to a careful proctoscopic examination with suitable instruments, perhaps in the knee-chest position, when the growth is not easily appreciated from below. Any complaint of tenesmus, with discharge of blood and mucus, with more or less pain and tenderness, local or referred, demands an examination sufficiently careful to reveal the nature and extent of the lesion and indicate the treatment. If such an examination call for an anesthetic, it should be administered. Practically every rectal cancer is a malignant ulcer by the time it is recognized, ulceration being favored by warmth and moisture.

Treatment.

—There are few malignant lesions anywhere about the body which require more good judgment in treatment than cases of cancer of the rectum. So much depends upon their location, their extent, the degree of infiltration, the age and general condition of the patient, that it is almost impossible to lay down succinct rules. The question of treatment hinges, first, upon the location and extent of the lesion; is it operable or is it not? When the lymph nodes of the pelvis or the groin are noticeably involved it is practically too late, under any circumstances, to hold out prospect of radical cure. When the disease has extended far above reach of the finger it is again late to expect much even from radical measures. When the prostate, the floor of the bladder, the vagina, or any of the pelvic viscera are involved it is again too late to justify them. There are wide differences of opinion between surgeons as to the propriety of extensive operations in serious cases. Mild cases are certainly much benefited and even actually cured by early and thorough removal, but this occurs too infrequently, because such cases are rarely seen sufficiently early.

The class of cases universally acknowledged to be inoperable, so far as radical measures are concerned, are nevertheless much benefited and their lives prolonged by a colostomy, the effect being to provide an easy and manageable outlet for fecal discharge, and to avoid the irritation and attendant difficulties associated with an obstructed and malignantly ulcerated rectal outlet. The surgeon has to select between some method of excision and colostomy. My own opinion is growing in favor of the latter, save when the prospect of complete excision is good. The opening is more manageable, the progress of the disease seems much checked, patients have better fecal control and live in far greater comfort, while their lives are placed in less jeopardy, and, in general, are actually prolonged. Thus a colostomy performed in a well-marked case of inoperable cancer of the rectum may permit of prolongation of life for two or three years, something not often attained by any other method of treatment.

Of the various radical operations some are made from below, i. e., by the perineal route, some by the so-called sacral route, and some from above. Of the latter it may be said that occasionally an annular cancer of the rectum is seen so favorably located that by opening the abdomen with the patient in the Trendelenburg position it is possible to make a complete excision of the growth, to remove enlarged lymph nodes, and to make an end-to-end reunion with success. In a case in my own practice nearly six years have elapsed since this operation was done, and the patient, a young woman, is still absolutely free from the disease.

Through the perineum the lower portion of the rectum may be attacked either by splitting the sphincter and dividing it posteriorly, completely dissecting out the gut from its surroundings, removing all infiltrated tissue, and then, by dividing the bowel above the growth, amputating the lower part. It may be possible to bring down the upper end and attach it to the mucocutaneous border of the anus, reuniting the divided sphincter, and aiming for a restoration to something like the original condition, which under quite favorable conditions is attainable. At other times it will be impracticable to thus attach the lower end of the tube because it has been too much shortened, and in these cases it should be brought out through a posterior incision just below the tip of the coccyx, or higher up if the bone has been removed. Here the rectal outlet is placed posteriorly, but is devoid of a sphincter. Something like sphincteric action can be provided by giving it a third or half of a revolution on its axis before fastening it to the external wound. After this expedient more or less control of solid fecal matter is afforded.

The more complete and radical operations, associated with the names of Kraske and other operators, include removal of the coccyx, and of the lower portion of the sacrum, which are usually completely excised, although certain “trap-door” operations have been devised. If the sacrum be not cut away above the third sacral foramen there is not much damage done to the nerves, while sufficient room is afforded for any removal that is justifiable. Some operators open the peritoneum, others attempt to avoid it. If the growth be attached to that membrane it becomes necessary. If peritoneal invasion can be avoided it is desirable. It is possible to completely expose the contents of the pelvis through such an opening, while from this direction, the gut being withdrawn after the peritoneum is divided, the pouch of Douglas may be opened and further removal of diseased tissue be effected. In all these operations the endeavor should be to disturb the mesosigmoid and the mesorectum as little as possible, in order to not interfere with blood supply, for reasons already mentioned when discussing the mesentery.

In all these operations contamination of the wound should be avoided, especially of the peritoneum, by clamping or ligating the bowel, or by amply packing and by every possible additional precaution. Bowel should be divided between two clamps and the divided edges at once thoroughly cleansed with compresses and with hydrogen peroxide.

One may read in the works on operative surgery descriptions of most extensive and elaborate operations of this general character, and of extensive and even daring feats of removal, where portions of the bladder, of the tubes, of the ovaries, even the uterus, have been removed. It has seemed to me that the surgeon should avoid operative gymnastics, especially in this region, so far as possible, and confine himself to measures which if successful would improve conditions rather than complicate them. My own judgment then is that in any case where so formidable an operation would be attempted by some, the best interests of the patient will be served rather by simple colostomy.

Early operations upon cancer of the rectum afford comforting prospects. It is not so much to the discredit of surgery as to the discredit of the patient’s judgment, and of the carelessness of the practitioners who first see these cases, that cancer of the rectum has become such a bête noir and is justly regarded as so serious and unpromising a measure.[60]