POSTERIOR LINEAR have never attempted to relieve a patient suffering from malignant trouble by means of this operation. In benign structures I have found the procedure a most excellent plan of treatment when combined with the subsequent use of bougies. Those surgeons who adopt this method for the relief of cancer speak highly of its efficiency, some going so far as to claim that it takes the place of both colostomy and excision.
Resection of the rectum per raginanl successfully performed in five cases. The patient being placed in the lithotomy position, the vagina is dilated. The cer vix is drawn down and Douglas's pouch opened by a transverse incision, the in testines being pressed back with flat sponges. The recto-vaginal septum is divided down to the rectal wall by a vertical incision in the middle line, ex tending from the post-cervical opening and including the sphincter ani. The hemorrhage can be controlled by for ceps and compresses. The posterior vaginal wall is now dissected off the rectum; lateral and anterior retractors may now be used, exposing a large oper ation site. The sigmoid can now be easily drawn down. The anterior rectal wall. including tne sphincter, is divided up to the lower border of the tumor, and the anal segment of the rectum separated by a complete transverse in cision an inch below the lower limit of the tumor. The proximal end of the rectum is grasped by a volsella, and separated by curved scissors from its coceygeal and sacral attachments up to the promontory. The mesosigmoid is loosened sufficiently to allow a healthy portion of bowel to be drawn well down. The rectum is amputated above the upper border of the tumor; then the sigmoid and sphincter segments are united end to end by silk sutures, passed from within outward. The incision in the anterior rectal wall is also closed by silk sutures, and the ends of the divided sphincter are united by buried catgut sutures. The sponges are now removed, and the peritoneum closed by a continu ous catgut suture. The vaginal wall is now sutured with silk-worm gut. A rubber drainage-tube, 1 inch in diameter, is now placed in the rectum.
The advantages of the vaginal route arc:— The sacrum and posterior bony wall of the pelvis are not disturbed.
The field of operation is as extensive and the anatomical parts as accessible as in the transsacral operations.
The peritoneal cavity is opened in both the vaginal and sacral operations, and in neither is it a source of great danger.
The diseased tissue is more accessible for inspection, and the extent to which the operation may be carried in an up ward direction is as great, if not greater, than by the sacral route.
The peritoneum may be drained freely through the vagina.
A perfect end-to-end approximation, either by suture or by the use of the button. may be secured. The preferable method of uniting the two ends is by interrupted sutures of silk, because as there is no peritoneum on the sphinc terie segment, failure of union with the button is to be feared.
The sphincter is retained and the per ineal body is restored. There is dimin ished action of the levator ani muscle.
When the operation is complete the parts are practically in their normal positions. J. B. Murphy (Phila. Med. Jour.. Feb. 23, 1901).
CURETTAGE.—In those cases in which the growth is within the lower three inches of the rectum and its character is such that extirpation is not possible and colostomy is not at the time necessary and the growth not hard, considerable temporary benefit may be given the pa tient by resorting to this operation. In selected cases it is followed by a diminu tion of pain, bearing-down sensations, and discharge, and the lumen of the bowel is enlarged.
In certain cases the combined opera tions of colostomy and of curettage will afford the patient much more relief than where one or the other procedure is in dividually adopted. It is true that only temporary relief is afforded by either of these operations, but in the majority of cases this is all we can offer the patient under any plan of treatment in vogue at the present time.
The medical treatment of cancer of the rectum presents but three points for con sideration: the daily evacuation of the bowels, the use of some soothing local antiseptic wash to cleanse the parts, and the relief of pain and tenesmus. The first indication may be met by the em ployment of salines: citrate of magnesia, Epsom salt, or phosphate of sodium. The second by enemata of a 2-per-cent. solution of ereolin, or the same strength solution of permanganate of potassium. The third indication for a time may be overcome by the use of iodoform sup positories (10 grains of the drug in each suppository used, if necessary, every six hours). The use of opium should be avoided as long as possible. The denar cotized tincture of opium is the best preparation to employ.