rapid course, and isjnuch more dangerous; indeed, sudden
death is not uncommon, as total obstruction takes place
quickly^ and unless colotomy is promptly performed the
intestine gives way above the obstruction, and death ensues.



206 CANCER OF THE RECTUM.

I have seen a good many examples of this, and always warn
the friends of what may happen. * Cancerous stricture of
the upper part of the sigmoid flexure or the descending colon
is not so immediately dangerous, although the obstruction
may be total. I saw with Mr. Sutton Sams, of Lee, an
elderly lady, who had total obstruction high up the bowel,
and yet lived for more than eight weeks. Another case I
saw in consultation with Mr. John M. Burton, also of an
elderly lady, who had a similar obstruction and lived for
many wrecks, though she had constant vomiting. Many cases
of this kind have come under my notice, where patients
would not submit to colotomy. I need not say that their
suffering is very great, and loudly calls for surgical inter-
ference. Af the same time the difficulty of ascertaining the
precise seat of the obstruction, in many instances, ties the
surgeon's hands.

I now come to the consideration of a very important but
unsatisfactory part of my subject, viz. What can one do
for the relief of these terribly unfortunate persons ?

1 have never seen any benefit result from the application
of caustics to growths within the bowel, but when a cancer-
ous mass protrudes, which, however, is a somewhat rare
occurrence, I have relieved pain and got rid of a good deal
of the growth by using the arsenite of copper with mucilage,
as a paste; this destroys rapidly without increasing the suf-
fering at the time; it does not cause bleeding, and, as far as
my experience goes, it is free from danger.

The treatment in the majority of cases of cancer still
resolves itself, for the most part, into an attempt to assuage
the suffering of the patient. Pain is generally mitigated by
the recumbent posture, and good, easily assimilated, nourish-
ing diet, with alcohol in moderate quantities. All varieties
of sedatives may be used with benefit, externally and inter-
nally, and when one drug loses its effect another should be
substituted. Opium in its several forms is the most effective
agent we possess. It may be used as a suppository in
which case the best formula is morphia, with glycerine and
gelatine (three of glycerine to one of gelatine), as this melts
very soon, and does not feel like a foreign body in the sensi-
tive bowel, as suppositories made of cacao butter so fre-

•
* Sir James Paget related a case to me where very little was thought
to be the matter with the patient until nine days before entire obstruc-
tion took place and death.



CANCER OF THE RECTUM. 207

quently do; injections of Battley's sedative, nepenthe, or
black drop in starch, sometimes afford great relief. Solid
opium by the mouth is a great favorite with me, but the
objection to it is that the stomach gets irritated, the appetite
fails, and the bowels are confined. Probably most patients
obtain the greatest comfort from hypodermic injections of
morphia; but no opiate can be used lon-g without inducing a
state of mind almost as unendurable as the pain of the dis-
ease and therefore great care should be taken to husband the
remedy as much as possible, never using a larger dose than
is absolutely necessary, bearing in mind that you may have
to rely upon it more or less, even for months. I have had
many patients who from small beginnings got to inject from
eight to fifteen grains of morphia in the twenty-four hours,
and the condition of mind of these patients was really fear-
ful. Many persons who had injected such, large doses, have
told me that they preferred the most excruciating pain to the
mental distress the morphia produced, and have, even of
their own accord, left off the drug and endured the physical
suffering.

It has recently been asserted by Mr. John Clay, of Birm-
ingham, that Chian turpentine has a curative action in cer-
tain cases of cancer. Following Mr. Clay's method, I have
administered this drug in forty-nine 'cases of malignant dis-
ease of the rectum, many of the patients taking it for several
months, even up to a short time before death. The turpen-
tine was genuine, being obtained, for the most part, from the
chemists recommended by Mr. Clay; in only two cases did I
see the slightest mitigation of symptoms. Both these patients
took the medicine for nearly twelvemonths, but the improve-
ment was quite evanescent, and the patients died.. In all
the other cases, either no effect was manifested or only a bad
one, viz., nausea and frequent derangement of the appetite
and functions of the stomach. The drug was exhibited in
the best way, both in solution and pill, and in many cases
combined with sulphur. I have seen several patients who
had been under Mr. Clay's treatment, but they were in no
way benefited any more than those treated by myself,
although one case was considered by Mr. Clay to be doing
very well, and was probably reported as cured.

When cancerous growths approach the anus considerable
relief may be obtained by dividing the sphincter muscles;
defecation is thus rendered easier, and no possible compres-
sion can be exercised. Usually, as I have said when speak-



2o8 CANCER OF THE RECTUM.

ing of stricture, a cancer of the upper part ot the rectum
paralyzes the sphincters, doubtless from pressure on nerves,
and the patient is not able to retain the motions, especially
if they are at all liquid. When diminution of the calibre of
the bowel is induced by cancer near the anus. Professor
Verneuil has proposed free division of the gut in the dorsal
median line, or even the excision of a segment of the
posterior wall of the rectum. The former operation I have
frequently practiced; the latter does not commend itself to
my mind.

In encephaloid of the rectum great temporary advantage
and much relief from pain may be obtained by tearing out
the growth by the fingers or a scoop (as the late Professor
Simon advocated in cancer of the uterus). I prefer my
fingers. You must be bold in doing this, and enucleate the
whole growth quickly and resolutely. If you tear away only
superficial portions, haemorrhage may occur to a considera-
ble extent, which must exhaust your patient, and no real
benefit will accrue.

I had a case under treatment in conjunction with Mr.
Pinching, of Gravesend, in the person of a member of our
own profession. An immense encephaloid growth almost
filled up his pelvis, and he came to London to see if I could
do anything for him. He was in such a condition that I
thought he could not bear colotomy, but I saw that if I could
remove the growth in great part without his losing blood to
any extent great relief must follow. Accordingly, assisted
by Mr. Pinching^ I made a free division of the anus, the
muscles and fat around which had been so thinned away by
the pressure of the growth that it was only like cutting
through thin, devitalized skin. Only one small vessel
appeared inclined to bleed, and this I immediately twisted.
I now passed my hand gently into the pelvis, got I fingers
well above the growth, and tore it out. A large mass was at
once removed. I then continued to remove all I could find,
and it came away, exactly like brain in appearance, and in
quantity sufficient to fill a good-sized pudding-basin. I had
come fully prepared with subsulphate of iron, the actual
cautery, sponges, and wool, in order to be able to plug at
once should haemorrhage take place, but to my astonishment
there was no bleeding worth mentioning, and the cavity from
which the cancer had been removed was dry and gray in
color, with red spots. As a precaution against secondary
haemorrhage I put in sponges powdered with the subsulphate



CANCER OF THE RECTUM. 209

of iron, but there was no bleeding at all. From the day after
the operation the patient rallied, lost his night sweats, ate
and drank all we gave him, and was able to return home in
a few weeks. After this he lived in comparative comfort for
two months, then, as the growth returned, he very gradually
died from exhaustion, nearly five months having elapsed since
he underwent my treatment. Twice since this I have carried
out this plan in a similar manner, and in both cases great,
though temporary, relief followed. I do not see why it
should not be adopted in some cases of epithelioma. I was
surprised to observe, in the three cases after the removal of
the cancerous growths, that the facial appearance of the
patients so immensely improved; in fact, they all lost the
malignant aspect, and not until the growth gradually
returned, and with it the poisoning of their blood and tissues,
did the countenance reassume its worn, haggard look. So,
also^ in respect to strength, freedom from pain, appetite, and
capacity for sleep, the change for the better was remarkable.
In this variety of cancer, though colotomy would afford in
some degree relief from pain, inasmuch as the abundant
cancer elements are still present, poisoning of the general
system would continue in full force, and thus extension of
the term of life is not to be obtained, and, indeed, can hardly
be anticipated; in such cases, where I have performed
colotomy, I have found the patients have rapidly succumbed.

Two operations have been practiced for the relief of rec-
tal cancer. The one is extirpation of all the diseased por-
tions of the rectum, which, further, is stated by some surgeons
to effect a positive cure of the disease in some cases. The
other operation is colotomy, lumbar or inguinal, which only
professes to relieve pain, and possibly extend the term of
the patient's life.

Extirpation of the rectum (as it is frequently termed),
broadly speaking, may be undertaken in any form of cancer
which does not necessitate the removal of more than four
and three quarters or five inches of the rectum in the male
and about one inch less in the female. Subject to the results
of increased experience, I should also say that if great
adhesions are formed to the sacrum or to the base of the
bladder and prostate gland, or to the neck of the uterus in
women, the operation is probably not admissible, and cer-
tainly not desirable. Again^ if any enlarged glands exist in
the inguinal or lumbar regions, the operation cannot be
recommended; lastly, I should say the patient ought not to
14



2IO CANCER OF THE RECTUM.

be SO exhausted as to render it doubtful whether the neces-
sarily rather free loss of blood would, to a great degree,
endanger life. The length of the rectum from the anus
which may be removed without opening the peritoneal cavity
differs in individuals, and the conclusions arrived at by
measurements of the dead body, or by taking plaster casts
of the reflections of the peritoneum, are fallacious^ and must
be taken as an approximation to the truth only. In a female
patient on whom I operated, Douglas' pouch was only two
inches from the anus. In a male fully five inches of the
rectum were removed, and the peritoneum never seen; and
in another male, in which not more than three and a half
inches were cut off, the peritoneum was opened and a coil
of intestine protruded. A point of considerable importance
in operating is to divide the levator ani muscle thoroughly
and dissect it carefully upward, by which means you get the
rectum to come readily down, and in making the necessary
traction on it you do not draw the peritoneum down with it.
Another point worth remembering is that the meso-rectum
is more developed in some subjects than in others, and
descends below the upper half of the rectum. Care must be
taken in using the knife close to the sacrum, as you may
easily divide the trunk of the middle hsemorrhoidal artery,
when severe bleeding will take place, and difficulty may be
experienced in arresting it. This accident has occurred to
me, but I was able to sieze the vessel and secure it quickly.
From the full and sudden rush of blood, however, I felt con-
vinced that a weak patient might readily die on the table.
It is not my intention to enter into the history of the opera-
tion of excision of the rectum, nor shall I describe the
various ways in which it may be performed; but I beg to
refer the reader who wishes the fullest information on these
subjects to the able and exhaustive work of Dr. Marchand,
entitled " Etude sur I'extirpation de I'extremite inferieure
du Rectum." I will only here mention that Paget, in the
year 1739, excised the rectum for cancer; that after this the
operation remained in abeyance until 1828, when it was
revived by Lisfranc, who performed it in several cases with
success. At a comparatively recent date it has been fre-
quently undertaken by both French and German surgeons,
and with such good results as to establish the operation on
a reliable basis. The Americans and ourselves have brought
up the rear; possibly we are more cautious and have had
our doubts as to the great benefits claimed for it by our



CANCER OF THE RECTUM. 211

foreign confrlres ; certainly we are justified in distrusting
such statements as Dieffenbach's, who says that he had had
thirty cases of successful extirpation of the rectum, the
patients living many years after the operation. We have
also felt incredulous as to the advantage derived from cutting
out the rectum, a portion of the urethra, prostate gland, and
base of the bladder, as did Nussbaum, who gravely assures
us that the patient recovered all his functions and lived for
three years.

My own experience of removing cancerous growths from
the rectum is not great. I find that I have excised segments
of the bowel by knife alone, or combined with the ecraseur or
ligature (elastic or inelastic), in thirteen cases, and in six-
teen patients I have removed the rectum in its whole cir-
cumference, the largest portions taken away being, in two
cases, five inches and five inches and a half in length,
respectively.

I shall not enlarge on my operations on segments of the
rectum, because the question to be determined is. Can one
cure a patient who has cancer — say epithelioma — by excising
the whole of the diseased portion of the rectum ?

Speaking generally of partial removals of the circumfer-
ence of the bowel, I must say I consider the operation unsat-
isfactory. In all my cases which I had the opportunity of
observing for about a year, either a return of the disease
took place in t]je rectum, or the glands in the groin became
affected, or there ensued disease, probably cancer, in
some internal organ, mostly the liver. I find seven out of
thirteen cases died within eleven months of the operation,
and in three there was a return of the growth in the rectum.
This may, of course, be attributed, and I think rightly, to
my not having totally extirpated the local disease; but in four
cases the disease did not return in the bowel, but in the
glands. One of my patients died suddenly, two days after
the operation, from syncope on getting out of bed. Another
died on the fourteenth day, from erysipelas. The four
remaining cases recovered from the operation, but I have no
knowledge of the ultimate result. In one case, a patient of
Mr, George Ord, the growth did not return until after one
year and five months had elapsed. I had, therefore, arrived
at the conclusion that partial removal of the rectum was an
operation which could not be very strongly recommended.
Another objectionable feature in my case was that, contrary
to the experience of some of my professional brethren, the



212 CANCER OF THE RECTUM.

patients had incontinence of faeces when a large portion of
the sphincters was removed All my cases were not epith-
elioma; some presented scirrhous nodules, as in the case I
mentioned, where the growth was situated over the prostrate
gland.

Case i. — My first excision of the whole circumference of
the rectum was performed at St. Mark's Hospital on the 2d
of March, 1874. The patient was a woman, forty-seven years
old, who was sent to me by Dr. Thomas. She was a widow,
with a family; she did not look very unhealthy, and was
fairly nourished, but she said she had become thinner. Six
months back she had been operated on in the London Hos-
pital, for fissure, but she did not get well; soon after the
operation the pain was as bad as before it. There was con-
stant gnawing pain in the anus, much increased on defeca-
tion, and she was obliged to strain at stool. Exa77iination. —
The anus was patulous, but just inside was a contraction
formed by hardish, ulcerated growths, which nearly encircled
the bowel. The extent upward w^as not more than an inch.
There was no history of syphilis nor any symptom. I had
no hesitation in pronouncing the disease to be epithelioma,
and I removed it by a circular incision around the anus
including the sphincter. I dissected the bowel up without
difficulty, as there was no adhesions, drew the gut outside,
and cut it off with scissors. I took care to have the bowel
held well out with a volsellum. There was smart bleeding,
but four vessels being tied, it all ceased. I then joined the
stump of the rectum to the skin with six wire sutures. On
the day after the operation there was much swelling, and on
the day following there was lividity of the skin and great ten-
sion, so I was compelled to remove all the sutures, and a
quantity of pus was discharged and the parts widely gaped.
I ordered charcoal poultices and injections of Condy's fluid.
After a few days the wound assumed a healthy appearance,
and the patient made good recovery. I was much astonished
at the way in which the rectum gradually grew downward
and joined the skin, forming an excellent cicatrix. Before
leaving the hospital she had some power over her motions, I
watched this patient for sixteen months, following her to a
distance rather than lose sight of her. No disease returned
in the rectum, but in eleven months she had abdominal
sysptoms; emaciation was very rapid; she suffered much,
and died sixteen months after the operation, having kept her
bed for five months.



CANCER OF THE RECTUM. 213

Case 2. — A man, aet. 36, was taken into St. Mark s Hospi-
tal, and operated upon by me on the 26th of October, 1874.
He had suffered from haemorrhoids, and had been under my
care fifteem months before. He continued well until three
months ago, when he began to suffer pain in the rectum, and
passed blood and mucus; the bowels were almost always
relaxed, and he had but little straining, but he had inconti-
nence of faeces. The patient was unhealthy looking, and
had lost flesh and strength. On examination a cancerous
growth was found encircling three-fourths of the rectum on
its dorsal surface; the anterior portion seemed uninvaded,
nevertheless, I thought it advisable to remove the gut in its
entire circumference, by an elliptical incision. A silver
catheter was passed into the bladder, to steady the urethra.
The part removed was about two inches in length; no diffi-
culty presented itself in the operation. . I did not put in any
sutures, but filled the wound with wool soaked in carbolized
oil. No bad symptoms followed, and the parts were quite
healed in four weeks. The patient returned to me three
months after the operation, with contraction of the anal ori-
fice. I made an incision to correct this, and he had no trou-
ble afterwards. Seven months subsequent to the operation
the cancer appeared higher up the rectum; he refused any
further surgical interferance. After a little time I lost sight
of him, and therefore do not know how long he survived.
For four months after the operation he was quite comfortable,
had no incontinence of faeces, and was able to do his work.

Case 3. — A man, in rather poor circumstances, but who
would not come into the hospital, was sent to me by Mr.
Slater, of Canonbury. I saw him first in January of 1875.
He was a spare man, about fifty. He had suffered pain for
some months, in the bowel; it was pretty constant and much
aggravated on action of the bowels. He felt weak and had
lost much weight. On examination I found a rather large,
cancerous growth, two inches from the annus; it did not
involve the whole circumference of the bowel; it was mov-
able in all directions. I could easily reach its upper border,
and bring the growth close to the anus. I proposed remov-
ing it, but the man declined. In March following he came
to me again, saying he had suffered so much that I might do
what I liked to afford him relief. Examination showed that
the cancer had approached much nearer to the anus, but
there still remained a zone of healthy mucous membrane
between the growth (which I believed to be epithelial) and



214 CANCER OF THE RECTUM.

the anus. There did not appear to be any important adhe-
sions except dorsally; anteriorly very little amiss was
detected, and the gut was quite movable. I determined on
excising the growth, and to leave the external sphincter by
carrying my knife around the bowel in the space between the
two muscles. I discovered when I made the incision, from
which blood flowed plentifully, that I could not safely
remove the growth, so I made a deep dorsal cut in the
median line, nearly to the coccyx. I was delighted to find
the amount of room this gave me, and how it rendered the
operation comparatively easy. In all my subsequent cases
I have commenced my operation by cutting from the point
of the coccyx well up into the bowel, a proceeding so
strongly recommended by Prof- Verneuil. No serious obsta-
cles were found, and I ablated about three inches of the rec-
tum, cutting well free of the growth. I attempted to bring
the stump of the rectum to the skin by sutures, as I hoped
thus to save the external sphincter, which I had preserved,
but the tension was too great, and I therefore only filled the
wound with sponges soaked in a weak solution of chloride of
zinc. The after progress, on the whole was satisfactory but
slow, and the wound took seven weeks in healing. This
patient died fourteen months after the operation. He was
in comparative comfort for twelve months, and had fair
command over his motions, unless they were liquid. The
disease did not return in the rectum, but the glands in the
groin became affected, and possibly also some internal
organs. He suffered much pain toward the last.

Case 4. — A gentleman, set. 60, came to me from the coun-
try saying he was suffering from stricture of the rectum,
which had troubled him for about eight or nine month ; he
had consulted several eminent provincial surgeons, and had
used bougies with temporary benefit. He was thin, but fairly
strong and active; the expression of his face was healthy.
On examination I found his bowel obstructed by a growth
which quite surrounded the gut; it was ulcerated in parts; it
commenced about an inch from the anus, and the zone meas-
ured about two inches at most in length; it was freely mov-
able in all directions; no glandular complications could be
detected. I advised its immediate removal. He went home
to consider the matter, to consult his relatives, and one of
the surgeons he had seen. He returned to town in a few
weeks and I operated upon him on the 26th. of January,
1876. I operated exactly as in the last case, save that I



CANCER OF THE RECTUM. 215

made the dorsal incision the preliminary step. In this case
the bleeding was very free, and I liberally used the actual
cautery to the cut surface of the rectum as well as to other
parts. The wound was filled with sponges steeped in a
weak solution of carbolic acid, and I introduced a tube into
the rectum in order that wind might escape, the retention of
which had much troubled my last patient. The wound
healed kindly. There was no fever after the first forty-eight
hours, and the patient suffered remarkably little. In
five weeks he went away quite satisfied and I expected a
good result; but I was disappointed, as in five months he
came to me with a return of the growth, quite near the anus,
involving the scar and the skin; it was a hard lump, the size
of half a walnut, and I advised him to let me cut it out; he
acquiesced, and I removed it freely, but did not take away
the w^hole circumference of the gut. This I afterwards
regretted, as I saw him in about three months again with
much more growth at the anterior part of the rectum. He
was now now weak and greatly broken in health, and despair-
ing of relief he refused any more active treatment. I heard,
from his friends, that he died just eleven months and a half
from the first operation.

Case 5. — I saw with the late Dr. Daldy a single lady, set.