44 Arch. Clin. Surg., 1877.
As to operative procedure, when the morbid growth is an epithelioma situated within a short distance of the anal opening an excision is not only justifiable, but may be recommended. The results show that its removal from this situation is as frequently successful as is its removal from the lip. When a cancer completely fills the lumen of the gut and plugs it so that the act of defecation becomes impossible, excision of the rectum and the establishment of an artificial anus are the two operative procedures open to the choice of the surgeon. A decided reaction of opinion has lately taken place among members of the profession relative to the latter of these; the few surgeons who did practise excision of the rectum in cases of cancer were looked upon as being rather unscientific and unsurgical. Billroth has excised the rectum 16 times, with 4 fatal cases; Dieffenbach performed it 30 times; Lisfranc had recourse to this operation as early as 1826; while the operation has been performed very frequently in this country, and with success.
Morton says: "In the spring of 1882, I was consulted in the case of a lady aged fifty-six who had suffered for two years from what were supposed to be internal hemorrhoids. An examination revealed the existence of a large scirrhous mass encircling about two-thirds of the gut, on the anterior part especially, and extending upward three inches. The patient was worn down by long suffering, but was otherwise in fair condition of health. With the assistance of Gross and Agnew, I excised the mass, which included the entire lower part of the rectum. The wound healed kindly, without an untoward symptom, and the patient was very soon enabled to leave her home for the seaside, where she passed the summer. The disease, however, resumed, but without any of the severe pains which she had had prior to the operation. Death occurred from gradual exhaustion seven months afterward."
He also relates the following case of excision of the rectum: The patient, a female aged thirty-five years, first noticed some rectal irritation about four years ago. This was followed by distressing pain during defecation and by hemorrhages; finally a tumor, which was described by her medical attendant as being like an opened umbrella, protruded, partly at first, then fully, through the anus. The growth seemed to be spongy in character, and was very vascular. It was removed by carrying a double-threaded needle through the mass, and thus ligating it. Upon the seventh day after the operation a hemorrhage occurred, which was controlled by plugging the rectum. Although the growth was removed, the patient did not make a good recovery; symptoms of rectal irritation continued. In September, 1884, the patient presented herself in a wretched condition, with bearing-down pains and frequent hemorrhages. Upon digital examination an elevated mass was readily detected upon the sacral aspect of the bowel. By carrying the fingers beyond this mass and making traction, it was brought down within working distance, and was excised along with the entire lower portion of the rectum. The freshly-cut edges of the gut were then drawn down and stitched to the mucous membrane just above the anus. The patient made a good recovery and has a serviceable anus.
R. J. Levis45 has operated upon two cases of cancerous growth in the rectum, removing the lower part of the bowel. The first case was that of a man aged sixty, who made a very good recovery from the successful operation, although three inches of the gut were removed. The second case was that of a man aged fifty-two, who had a carcinomatous tumor the size of a hen's egg at the right side of the rectum. The section of gut excised was about one and a half inches in length. The patient died of peritonitis upon the fourth day after operation. At the autopsy there was no wound found in the peritoneum, the lowest point of which was one inch above the end of the excised bowel.
45 Surgery in the Pennsylvania Hospital, pp. 81-83.
The etherized patient, his bladder having been emptied, should be placed in the lithotomy position. If a male, a sound should be passed into the bladder. An incision is then carried from the centre of the perineum along the raphé to the anterior margin of the anus, encircling the latter by two semicircular cuts and continuing the division directly back to the coccyx. In the female the incision should begin just posterior to the vagina. If the anus is not included in the diseased mass, the external sphincter may be spared by raising the skin and the muscle together and turning them on each side. When the lower end of the rectum is reached the dissection should be made entirely by the fingers or by the handle of the knife, tying vessels as they spring. Double ligatures should be introduced through the gut from its mucous surface outward, and, when possible, then stitched to the skin at the margins of the wound. The bowels should be controlled by opium for the following eight or ten days.
The other operative procedure is lumbar colotomy. This was first advocated by Amussat in 1839, when he appeared in a treatise upon the subject entitled On the Possibility of Establishing an Artificial Anus in the Lumbar Region. It is denied that he ever performed this operation. It has happened to sound surgeons and skilful operators, when the patient has been very muscular or very fat or when the colon has been collapsed, that they have been at length compelled to abandon the search for the gut and to stitch up the external wound. Allingham states that the cause of failure often is that the colon is searched for too far from the spine, resulting, in the opening of the peritoneum, in the starting up into the wound of a mass of small intestine which baffles the operator very seriously. He, having made more than fifty dissections, has come to this conclusion: "that the descending colon is always normally situated half an inch posterior to the centre of the crest of the ileum (the centre being the point midway between the anterior, superior, and posterior-superior spinous processes)." An incision four inches in length should be made midway between the last rib and the crest of the ileum. The incision may be made transverse, or, better, obliquely downward and forward, as suggested by Bryant. Allingham says that care should be taken to preserve the original length of the incision down through all structures, lest when the operator approaches the gut he finds himself working in the apex of a triangle the base of which is the line of the wound. If the surgeon has reason to expect the gut to be collapsed, an attempt should be made to distend it with some fluid. The intestine should be drawn well out through the wound, and a longitudinal opening an inch in length made in it. The edges of this are to be stitched to the edges of the skin. Fecal matter is much less likely to flow into the wound if the sutures are passed through the intestine previous to opening it. A weak carbolated wash is all that is required as a dressing. In one case of stricture of the rectum from a scirrhous mass, in which Morton performed colotomy, an immense cyst of the kidney, which was somewhat puzzling for a moment, protruded in the wound. After emptying the cyst the gut was readily discovered and opened.
DILATATION AND INFLAMMATION OF THE RECTAL POUCHES.—This is a comparatively rare condition of the rectum, called by Physick encysted rectum, which is treated by bending the end of a probe into a hook, passing it up into the bowel, and then withdrawing it with its extremity resting against the surface, so as to engage and draw down the pouches, the straining or bearing down of the patient assisting in their extrusion; they may then be incised or cut off with a pair of curved scissors.
LOSS OF CO-ORDINATION IN THE MUSCLES OF DEFECATION.—In those cases where it can be ascertained that this curious trouble is not symptomatic, sympathetic, nor reflex, the treatment must be directed to the building up of the general health, such as electricity, baths, asafoetida, and iron. Regular outdoor exercise should be enforced.