Cancer of the Rectum. 335

I regret that my experience with the other tests is not yet sufficiently large to warrant the expression of an opinion. I have, at any rate, satisfied myself as to their accuracy with regard to normal individuals.

I t is not easy to obtain a supply of suitable cases just when one requires them, but the results obtained hitherto lead me to hope that, with extended opportunities, my experience will coincide with that of other observers, who find these tests of assistance in trying to illuminate a very dark corner of our complex organism.

ART. XVI. - -A Short, Com~unication on Cancer of the ] ~ e e t u m . a B y WILLIAM TAYLOR, M . B . , F.R.C.S . I . , Surgeon to the Meath Hospital and County Dublin Infirmary.

DURIN(~ the past eighteen months out of a number of cases of rectal cancer that came under my care in four only was it possible to perform a complete radical operation. These cases, I thought, might serve as a suitable text for some remarks which I hope may excite discussion and elicit from the surgeons present any views they may now hold as to what the radical operation for cancer ()f the rectum should

be. The first case was that of a gentleman, aged about 70

vears, who had been complaining for some months of the passage of blood, mucus and muco-pus. Nothing could be detected by digital examination, but by the sigmoidoscope a small cancerous growth was seen high up.

The abdomen was opened in due course and a small, freely movable growth was found in the pelvic colon. A few enlarged glands wer~ present in the mesentery, but there were no evidences of secondary deposits elsewhere.

I t was obvious that free removal of the visibly affected gut would render it impossible to re-establish the contin- uity of the bowel by end to end anastomosis. It was there- fore decided to remove the entire pelvic colon and rectum.

Read before the Biological Club on Tuesday, October 21st, 1913.

336 Ca~ccr of the Rectum.

This was accordingly done--the cut end of the sigmoid flexure being brought out through the split muscles in the inguinal region to form a permanent anus.

The abdominal part of the operation completed, the bowel was removed from below by the parasaeral route.

The entire operation took almost two hours to finish, but, I regret to say, the result was unsatisfactory, as the patient died four days subsequently.

On thinking over this ease since, I feel sure I should have done much better for the man had I contented my.qelf with the free excision of lhe visible expression of the disease, closed the divided end of ~he rectal segment and infolded it by a purse-strin~ suture instead of removing the entire lower segment. The pelvic peritoneum then eon/d have been sewn across so as to shut off the abdominal cavity and the blind rectal segment could have been syringed gently at intervals. The time required would have been reduced to at least one half, possibly one third, and the risks of shock and sepsis correspondingly diminished.

The second ease was that of a lady, aged 50 years, upon whom Dr. Hastings Tweedy very kindly asked me to assist him to operate. The condition for which Dr. Tweedy was operating" was a uterine fibromyoma, but the patient had been complaining for some months of rather indefinite in- testinal ~rouble--increasing constipation with eolicy pain and occasional mucous discharge. The hysterectomy com- pleted, a small carcinolnatous ~rowth was found occupying the lower portion of the pelvic colon, so that a clamp could not be placed below the growth for the purpose of resection and anastomosis. I therefore decided to divide the sigmoid flexure and remove the entire pelvic colon and reetmn. The sigmoid divided, the pelvic colon and rectum were separated to within about three inches of the anal margin, at which point the bowel was cut across and removed, the remaining lower segment was denuded of its mucous mem- brane, after which the sigmoid flexure was mobilised and prolapsed through the lower segment and sutured to the skin at the anal margin. A few points of suture were also

By MR. WILLIAM TAYLOR. 337

passed through the upper end of the lower segment and the prolal)sed si~moid. An opening was then made through the posterior vaginal fornix, and a gauze drain passed into the operation region. The per i toneum was brought across from each side of the pelvis and sutured carefully round the sigmoid flexure above the ~a.uze drain, thus closing off the peritoneal cavity completely. Another gauze drain was brought from the operation area out lhrongh the lower angle of the abdominal wound which was dosed in layers. The subsequent course of the ease was uneventful. The lady was able to leave hospital in four weeks, has since gained over a stone in weight, and is a.t present in perfect health. I t is now one year and six months since the operation was performed.

The third ease was that of a woman, aged about 5 ~ years, who was sent to me to the Meath Hospital by Dr. Winder, of Glasnevin, suffering from symptoms of rectal cancer. A orowth was detected as high up as the finger could reach. After the usual prel iminary operation, the abdomen was opened, when it was determined that it was possible to remove the trouble completely. Bearing in mind the facility with which ] was enabled to extirpate the rec- tum and pelvic colon in the former case after hS, s tereetomy had been performed, ~ at once removed the uterus. The diseased area of bowel was then removed just as in the former ease, and the sigmoid brought out through the anal canal, which had been denuded of its mucous membrane . About one and a half inches of the lower end of the sigmoid sloughed off, but otherwise recovery was uneventful , and the pat ient has perfect control over the bowel and is in perfect health.

The last ease was that of a man, aged about 60 years, who was sent to me by Dr. Jacob, of Maryborough, with the diagnosis of rectal carcinoma. The growth was situated about five or six inches above the anal margin. After the usual preparat ion, the abdomen was opened and carefullv explored. There were no evidences of secondary deposit. Having regard to the situation of the growth,

338 Cancer of the Rectum.

which was just at the junction of the pelvic colon and rectum, it seemed to me that the safest procedure, so far as the pat ient was concerned, was to divide the sigmoid and ext i rpate the ent i re bowel below. The sigmoid divided, the bowel was separated as low down as possible af ter which the per i tonemn from the pelvic sides was sutured ore2 a gauze sponge which was packed over the separated bowel. The abdominal wound was closed after the pe rmanent anus had been established, by bringing" the lower end of the upper siglnoid segment through the split abdominal muscles.

The pat ient was then placed in an exaggerated l i thotomy position, and the entire bowel and anal canal were com- pletely excised. Free drainage was employed.

The subsequent course of the case was satisfactory, the pat ient being able ~o re turn home in less than four weeks after the operation.

Two impor tant principles are to be borne in mind, viz. : the complete removM of the local disease with as much adjacent tissue as may possibly seem to be affected, and the removal, as far as possible, of the associated lymphatics. Mr. Fagge has recently demonstra ted an extension down- wards of the eaneerons infection into the lymphat ics of the anal e~/nal without visible involvement of the canal itself. This would indicate that the anal canal should always be removed in any operation under taken for the complete ext i rpat ion of rectal carcinoma. Mr. Hand ley has shown tha t eancerou~ permeat ion may be found in the bowel wail as high as six inches above the obviously visible limit of the disease.

This observ,~tion would indicate that a considerable area of bowel above the visible site of disease should be re- moved. ~If these demonstrat ions of Fagge and H a n d l e r are accepted as correct it means that every radical opera- tion for rectal carcinoma should consist in the removal of the entire bowel from the sigmoid to the anal margin together with the associated lymph nodes. \Vhether .sueh an extensive operat ion is absolutely necessary is still a disputed point, but, it may be said that the majori ty of

By MR. ~u TAYLOR. 339

the younger generat ion of surgeons are of the opinion that it is so.

Granted that such an extensive operation is necessary it can only be satisfactorily carried out by means of a com- bined abdominal and perineal or sacral operation performed in one or two stages.

By such a procedure the opera five l rea tment of rectal carcinoma is brought more into line with the modern operation for cancer in other s i tuat ions--notably the breast. By such a method of operating, cancers which, by the perineal or sacral routes, would be considered inoper- able, can be readily removed.

I t may be said that it is seldom one finds that a growth which would be considered readily removable is associated with any extensive glandular involvement.

On the other hand it must nob be forgotten that one frequently finds that a secondary deposit has already occurred in the liver in a case in which there is practi- cally no glandular enlargement and ifi which the pr imary growth is still very freely movable. Such a condition can be discovered only by palpat ion of the liver th rough the opened abdomen. No good result could be expected to follow rectal excision in such a ease, and yet, if .surgeons religiously followed the perineal or sacral methods of operating, many such eases would be, and I believe, are, operated upon.

I have opened the abdomen in four eases with the object of performing a complete combined abdomino-perineal or sacral operation, but, unfor tunate ly , secondary deposits were discovered in the liver. The local conditions were eminent ly suited for complete removal. In one of these cases the growth was situated in the pelvic colon, so that I was able to excise it and do an end to end anastomosis so as to prevent the inevitable obstruction. I t seems strange that in each of these four eases the secondary de- posits in the liver were only detected upon the diaphrag- matic surface.

The mortal i ty of the combined abdominal and perineal

340 Cancer o] the Rectums7.

or sacral operation seems to be the chief stumbling-block to its general adoption. I t is put down by different opera- tors as varying from fifteen per cent. to forty per cent . , a somewhat wide variation.

I think it. cannot be doubted that this high morta l i ty is at tr ibutable in some measure to the fact that many cases are operated upon bv this method which would otherwise have been deemed inoperable, and condemned to much misery and certain death. The combined eperation per- formed in two stages should give a much reduced morta l i ty as compared with the complete operation performed at one sitting.

W. J. Mayo states in a recent paper that the combined operation performed in two stages i~ at tended by a mortal i ty of less than one half that of the combined operation completed in one stage. For cancer situated in the lower part of the pelvic colon in patients not suited for prolonged operative procedures the best method of t rea tment , it seems to me, is to simply excise the growth with as much bowel above and below as may appear advisable, and where it seems impossible to perform an anastomosis let the cut end of the lower rectal segment be dosed and the closed end inverted by a purse-str ing suture. Close the pelvic peri toneum over thi~ and bring the lower end of the sigmoid segment throngh the left rectus muscle to form a permanent anus. The blind rectal end thus left might be removed at a later date if Fagge ' s demonst ra t ion is accepted, or it may be left and syringed at intervals to wash out the mucous secretion. By such a pro- eedure the t ime necessary for the eompletion of the operation eonld be reduced by at least one half, with a corresponding rednetion in the shock and risk of sepsis.

I t can easily be seen from what I have slated above that [ am convinced that an abdominal section should always be performed as a prel iminary to rectal excision, no mat te r what the subsequent steps mav be, and I also feel con- vinced that a combined abdomino-perineal or sacral operation is that which in the majori ty of eases will

By MR. WILLIAM TAYLOR. 341

give the best results. I n s tout or enfeebled pat ients , I believe t ha t cancerous g rowths s i tuated abou t the junct ion of the pelvic colon and rec tum can be mos t satisfactorily t rea ted by dividing the sigmoid flexure and establ ishing a p e r m a n e n t anus through the left rectus muscle, af ter which the pelvic colon with the growth can be separated and the bowel divided well below the disease. The lower cnt end should then be closed and infolded by a purse str ing suture and the per i tonemn drawn over it.

i n men , I th ink, it is much safer to coml)lete the com- bined operat ion by the es tabl i shment of a pe rmanen t anus ra ther than make any a t t em p t to bring the siginokl down to the normal anal region.

T HE TYI 'E OF B A C I L L U S IN T U B E R C U L O S I S OF THE BONES AND

J O I N T S .

TUE view that tuberculosis of the bones and joints is almost exclusively due to the human type of tubercle bacillus is emphasised in tile D,e~tsche medizinischc Wochenschrift for September 18th by Dr. B. M611ers, K ocl~'s late assistant. His investigations in 12 cases of tuberculosis involving the bones and joints failed to demonstrate any but the truman type of tubercle bacillus. Of the patients examined, three were between the ages of five and sixteen, the rest being older. Pure cultures of the bacilli were obtained in every case; in one case three cultures were obtained at different periods, and in another case two cultures. From the 15 cub tures thus obtained 49 rabbits were inoculated with a dose of 10 mgm. each. These subcutaneous inoculations, which were to a certain extent supervised by Koch, conclusively proved, according to Dr. MOilers, that only the human type of tubercle bauillus was present, l i e has also collected the observations on this subject made by 15 workers in 163 cases (including the 12 cases already referred to) of tuberculosis of the bones and joints. Of these, only four were associated with the bovine type of bacillus. The remainder were un- doubtedly due to the hurnan type. In other words, onl S 2.45 per cent. of these cases showed the bovine type oi bacil lus.--The Lancet, October 11, 1913.