CANCER OF THE RECTUM.—The only treatment holding out the pros pects of cure is the complete removal of the lower end of the bowel, and in some instances success has followed the removal of the entire rectum and sigmoid. The most apparently hopeless cases sometimes succeed when the growth can be completely eradicated. No better instance can be quoted of the value of the operation than the following: A lady under the care of the writer early in 1886 suffered from mild symptoms of ob struction of the bowel for several weeks, caused by a malignant stricture just within the reach of the finger-tip; the case was pronounced as hopeless and unsuitable for operation by one of the most eminent and experienced surgeons in London. Mr. Cripps excised the lower end of the bowel from the perineum in May of that year, and the tumour was knonstrated to be malignant; this was further shown by a return of the disease in the colon many years afterwards, requiring colotomy. The patient survived in comparative comfort till 1918.
The operation is only contra-indicated when the tumour is immovable and the neighbouring organs and glands implicated.
if the cancer be near the lower end of the rectum it can be excised through the perineum, and the sphincters usually will require removal; if high up, either the sacral or the combined operation should be selected and the sphincters preserved.
For the perincal operation a deep incision is made round the margin of the anus and prolonged in front to the middle of the perineum and backwards to the tip of the coccyx. The levator ani muscles arc cut and the lower end of the gut is then dissected out, divided well above the growth, and the free end of the divided bowel is brought down to be attached by sutures to the margins of the anus when the tension of the parts justify suturing. The wound is then packed with gauze, and the bowels locked up for several days.
Kraske's operation is necessary to reach high growths; the incision of the former operation is prolonged backwards beyond the coccyx and over the middle of the sacrum for half its length; the coccyx, and if necessary the lower portion of the sacrum, is removed, and after the gut has been freed from all its attachments and brought down, it is cut across, the lower end being sutured to the sphincter when practicable. This latter
desideratum is facilitated by division of the mesenteric attachment of the upper end of the rectum or lower portion of the colon. Some surgeons insist upon the necessity of a preliminary colotomy or colectomy with the view of preventing contact of the extensive wounded surface with the bowel contents during the slow process of healing; it should always be resorted to when the bowel cannot be emptied before operation and when symptoms of acute obstruction have supervened.
When evidence exists of involvement of the lower end of the colon the combined operation is selected. The abdomen is opened in the middle line, and after freeing the attachments of the rectum and sigmoid, cutting the bowel across and applying ligatures, the abdominal wound is closed and the divided bowel with its contained tumour is withdrawn through the perineal incision as before described, and the lower end of the divided bowel brought down.
Miles, after opening the abdomen in the middle line, performs a colostomy and removes the whole bowel below this point. This evades the difficulty so often experienced of bringing the bowel after removal of the growth down to the anal orifice.
In all cases beyond the hopes of excision much relief may be obtained by judicious feeding and enemata, and when obstructive symptoms super vene the operation known as colotomy, or colostomy, should be per formed. This consists in opening the sigmoid flexure of the colon, and securing it to the lips of the skin wound in the left groin, thus establishing an artificial anus. When the symptoms are not acute this operation should be performed in two stages, the coil of bowel withdrawn being opened by the thermo-cautery three or four days afterwards in order to permit the formation of adhesions.