Packing of the wound with iodoform gauze should be adopted to prevent in fection, and need not be removed till it shows a tendency to become loose, about the end of the first week.
Seventeen cases of amputation of the rectum by Kraske's method: 3 of the patients died. giving a mortality of 17.07 per cent. Of the 14 cases traced, 6 have now passed beyond the three-year limit and may be considered reasonably safe from recurrence. Two of the tnen, in site of the loss of the coccyx and part of the sacrum, ride bicycles with ease. W. W. Keen (Jour. Amer. Med. Assoc., Aug. 13. 'OS).
J. M. Mathews (N. C. Med. Jour., Apr. 20, '98) states that unless all tissues in volved in the cancerous disease can be removed, an operation is useless. The rectum is contiguous to a large tion of glands and lymphatics. Cancer situated above and not involving the sphincter-muscle is often an insidious disease. When the mass has so far tended as to embrace the whole rectum, it is safe to infer that the infiltrative process has so extended that it has braced structures which cannot be moved; hence to resect simply the mass in sight would avail nothing. If, on the contrary, the growth can be circum scribed, and the assurance had that all diseased structures can be removed, then resection, or rather extirpation, should be advised. Operation is much more preferable than to perform a colostomy in such a case. The latter can only be a palliative, if that; while the former anticipates a radical cure. :Mathews avoids such operations as Kraske's if a lesser one will accomplish the purpose. Removing portions of the rectum by the simple circular incision and a careful section of the gut with the fingers has been practiced by him.
Among the advantages of the vaginal method of extirpation of the rectum are the following: The vagina can be made to take the place of the extirpated por tion of the rectum. The excision can be done as high up as by the sacral method and with less traumatism, and, in case the peritoneal cavity is opened, with less danger. An intraperitoneal exploration of the tissues about the rectum can be made before disturbing the rectum. If the operation has to be abandoned after the incisions are made, the wound is less formidable and in a better place. The patient is more comfortable after the operation than after the sacral methods. Price's abdominal method possesses nearly all of these advantages, but is more dangerous, necessitates a removal of the uterus, and cannot be adapted to eases extending low down in the rectum. MeArthur's method is more
dangerous in eases high enough up to involve an opening into the peritoneal cavity, and in all cases involves more traumatism. By ford (Annals of Surg., Nov., '90).
In rectal cancer metastases occur late. Even if in operating some glands which are infected are left behind, the progress of the disease in these limited areas may he extremely slow. There are numerous examples on record of prolonged life after rectal excision, and many cases have been recorded of non-recurrence for six, eight, and ten years. The mortality of rectal excision by sacral operation varies from 20 per cent. to 25 per cent. Czerny's mortality was 5.4 per cent. by the perinea' route, 19.4 per cent. by the sacral route; Iversen, 25 per cent.; Al bert, 18 per cent.; Ball, 8 per cent.; and Paul, 14 per cent. E. H. Taylor (Annals of Surg., Apr., '97).
CoLoszomv.—Colostomy is quite prac ticable in a large number of instances, and the benefits derived from its per formance are thus minutely described by Charles B. Kelsey (N. Y. Med. Jour., Nov., '92): "It relieves pain: does away with the constant tenesmus and charge from the rectum, which by their exhausting effects are the immediate cause of death; delays the development of the disease by preventing the straining and congestion of defecation; prevents absolutely the complication of intestinal obstruction, which is another cause of death; enables the patient to sleep, eat, and gain flesh, and often makes him think himself cured in spite of the plain est prognosis to the contrary. Instead of his passing his days and nights upon the commode, wearing out his life in his ef forts to free the bowel from its irritation, he has one or perhaps two solid faecal evacuations from the groin in twenty four hours." The benefits to be derived from colostomy are not exaggerated. It is the operative procedure indicated when a cancer has reached the stage of operative interference and has passed beyond the time when the surgeon reasonably expects an extirpation to af ford a radical cure.
During the last eight years, 720 cases of cancer of the rectum seen, and ex cision performed 62 and colostomy 138 times. if the patient is not over 45 years of age, excision offers very little prospect of permanent success. Ailing ham (Lancet, Apr. 25, '96).