Excision 
OF 
Cancer of the Rectum, 
An Analysis of One Hundred and 
Forty Cases. 
BT 
CHARLES B. KELSEY,; M. D. 
REPRINT PROM 
sCf)e 'Neto Yorfe s®cfcfcal Soucnal. 
December, 1880. This Paper is reprinted from The New York Medical Journal 
for December, 1880. 
The contents of that number are as follows: 
Original Oommunications. 
PAGE 
The Human Face: its Modifications in Health, 
and Disease, and its Value as a Guide in 
Diagnosis. By Ambrose L. Ranney, 
M. D., etc 561 
On the Management of the Second Stage of 
Natural Labor. By William T. Lusk, 
M.D., etc 595 
An Analysis of One Hundred and Forty Cases 
of Excision of Cancer of the Rectum. By 
Charles B. Kelsey, M. D., etc 608 
Visual Purple. By W. C. Ayres, M.D.... 619 
A Case of Abscess of the Abdominal Wall, in 
a Patient with Subclavian Aneurism. By 
T. R. Chambers, M.D 623 
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Single Number, 40 Cents. Yearly Subscription, |4.00. AN ANALYSIS OF ONE HUNDRED AND FORTY 
CASES OF EXCISION OF CANCER'"' OF THE 
RECTUM. 
FORTY 
CHARLES B. KELSEY, M. D., 
SURGEON TO THE INFIRMARY FOR DISEASES OF THE RECTUM, NEW YORK. 
The treatment of cancer of the rectum by excision has 
not yet been accepted by the surgical world as a substitute 
for other measures, even in cases best adapted for the opera- 
tion, although it can not be denied that a radical cure has 
sometimes been obtained, and that in many other cases life 
has been prolonged beyond what could have been hoped for 
by any other means of treatment. It is no less true that the 
operation is one of great danger, and that there are not lack- 
ing those whose experience has led them to believe that life 
was rather shortened than lengthened by it. By these it is 
claimed that in lumbar colotomy we have a safer method of 
relieving pain, and delaying the progress of the growth, and 
in both these ways prolonging life. American and British 
surgeons hold rather to this latter idea, while the French and 
the Germans favor excision. 
Again, lumbar colotomy has been tried many times. It is- 4 
comparatively safe of performance, and in the vast majority 
of cases it gives a certain amount of relief; while in excision 
the surgeon is treading on newer and less certain ground. 
The operation itself is surrounded with dangers. He fears 
either immediate death for his patient, or a speedy return of 
the disease ; and he turns to the more common treatment with 
the reliance that he is pretty sure to do some good to the suf- 
ferer, and leaves the newer ground for more venturesome 
operators. 
There are several questions yet to be answered concerning 
excision of the rectum for cancer, and most of them can only 
be answered by experience. For the purpose of arriving at a 
knowledge of what experience has already taught in this mat- 
ter, I have collected the reports of operations up to the present 
time as far as they are attainable. I can only regret, in pass- 
ing, the incompleteness of the record in many of the pub- 
lished cases—an incompleteness depriving them of much of 
the value they would otherwise possess. It amounts to very 
little, in the consideration of a question such as this, to know 
that a patient of a certain age had some kind of cancerous 
disease in the rectum, that some sort of an operation was done, 
and that in a certain number of days or weeks the patient 
died or left the hospital with the wound more or less cica- 
trized and with more or less control over the faeces; and yet 
in a large proportion of the following cases this is the total 
amount of information to be derived. 
I have, however, tried to glean all that could be gathered 
from the material in our hands, and submit it as it stands, 
subject to any modifications which a larger collection of better 
reported cases may make necessary.* 
The questions for which a solution has been sought are 
chiefly these. What are the dangers, and what is the mor- 
tality of the operation ? to what class of cases is it applicable? 
what are its results as a curative and as a palliative measure? 
* Instead of copying cases in full or preparing a table (troublesome both to 
writer and publisher, and very likely to be tiresome to the reader), I shall give 
at the close a list of the operators, with reference to the place of record. I have 
been at no exhaustive search to compile a complete list of operations, but have 
gathered together those best known and most easily attainable. 5 
how do these results compare with those of lumbar colotomy ? 
and, finally, the results as to the control of the fecal evacua- 
tions. 
Considering the operation, first, merely as a surgical proce- 
dure, wre find that in twenty-two cases death followed as a 
direct result of the interference. The causes of death, in 
their order of frequency, were: peritonitis, ten; pelvic cellu- 
litis and phlebitis, four ; septicaemia, three; exhaustion, three ; 
haemorrhage, one ; and erysipelas, one. Of these fatal results, 
four were due to accidents which may attend upon any surgi- 
cal operation, viz., those due to erysipelas and exhaustion ; 
and the others were from causes having their origin in the 
peculiar nature of this operation and the parts operated upon. 
Considering these alone, we find the three great dangers of the 
operation to be peritonitis, pelvic cellulitis, and septicaemia. 
The single death from haemorrhage in one hundred and forty 
operations may, I think, fairly be dropped out of considera- 
tion, especially as the operation may, if desired, be rendered 
almost bloodless by the use of the ecraseur or galvanic cautery. 
I have tried to discover whether there was anything in the 
nature of the individual cases which were fatal to account for 
that result, and we find that in thirteen of them in which these 
data are given the situation and extent of the disease are de- 
scribed in eight as follows: (I.) The inferior extremity of the 
rectum was completely surrounded with hard, knobby tumors 
encroaching upon each other, causing a stricture through which 
there existed scarcely any passage, and extending so high that 
their upper limit could scarcely be determined by rectal touch. 
The recto-vaginal septum was involved in the disease to such 
an extent as to render the isolation of the latter impossible. 
The peritonaeum was opened. (2.) The anus was surrounded 
with carcinomatous nodules; the disease reached four inches 
into the rectum, and the mass was adherent to the sacrum, 
coccyx, and posterior wall of the vagina. (3.) The disease 
completely surrounded the anus, reached three inches up the 
rectum, and the inguinal glands wmre involved. The perito- 
naeum was opened. (4.) The operation involved three inches 
of the rectum, and the peritonaeum was wounded. (5.) The 
disease extended beyond the reach of the finger, and only a 6 
part could be removed. (6.) The rectum was completely sur- 
rounded for a distance of three inches. (7.) The disease be- 
gan about six centimetres above the anus, was continuous on 
one side with a mass of the size of a hen’s egg, which was fixed 
to the pelvic wall, and extended beyond the reach of the fin- 
ger. The peritonaeum was opened. (8.) Nine and one half 
centimetres were removed, and the peritonaeum was opened. 
These cases seem to point to a very evident relation be- 
tween the extent of the operation attempted and the fatal 
result; and I do not hesitate to say that in such extensive 
disease as this, where the removal necessarily involves the 
danger of wounding the peritonaeum, the operation is contra- 
indicated. It is true, not only that disease more extensive 
than any described in these fatal cases has been safely re- 
moved, but that the operation has been followed by a long 
period of health; and yet I can not regard such a result as 
other than exceptional, nor do I consider that the slight chance 
of obtaining it counterbalances the risk of immediate death. 
The surgeon is never compelled to this operation to relieve 
suffering. There are other and safer means always at com- 
mand. 
I shall not stop at this time to discuss the question as to 
how much of the anterior wall of the rectum is uncovered by 
peritonaeum. There is an old rule for applying the trephine, 
that in every instance the operator should remember that some 
skulls are very much thinner than others, and he should act 
on the supposition that the particular point upon which he is 
operating is the thinnest part of the thinnest skull ever seen. 
Something of the same kind might be said of the peritonaeum 
over the rectum ; and everybody who has studied the anatomy 
of the part knows how various are the opinions of different 
authorities on this point. Nevertheless, a line of danger can 
be marked out, and that line is about three inches from the 
anus. It is true that more than this amonnt of the rectum 
has been removed without encountering the peritonaeum, and 
it has been opened below this point; but I should not, for my 
own part, hesitate to try to remove three inches of the bowel 
for a cancer, and within a few weeks I have refused to attempt 
to extirpate in an otherwise suitable case, because the disease 7 
passed this line. The index finger is a good guide. What is 
well within its reach in a hand of good length, it is safe to try 
to remove, provided it does not involve surrounding tissues 
to an extent which renders its complete removal impossible. 
Whatever may be said of the impunity with which the peri- 
tonaeum may be opened in other parts of the body does not 
seem to apply here; for I have been able to find but three 
cases in which that accident was not followed by a fatal 
result. 
Regarding the question of radical cure, we find difficulty 
in establishing exact dates, and have to take into considera- 
tion the reputation of the reporter. We find, however, that 
in one hundred cases (deducting those immediately fatal, and 
seventeen which passed out of observation immediately after 
operation) we have six cases of reported permanent cure, in 
which there had been no return for at least ten years. Three 
of these are reported by Yolkmann, two by Yelpeau, and one 
by March, of Albany. 
In one case the patient was alive and well eleven years 
after the first operation, though there had been two returns 
and subsequent removals (Yolkmann). These are perhaps 
the only cases which it would be proper to consider as per- 
manently cured, though others might be included in that 
category. But, for the sake of exactness, I give the subse- 
quent histories of the cases wherever they are mentioned. 
In one case the patient was alive and well six years after 
the operation; in two others, five; in four others, four; in 
three, three; and in five, two years or a little over. Nine 
are stated to have been alive and well, with no sign of return, 
at a year or a little over after the operation, and sixteen were 
reported in the same condition at times varying from two 
months to one year. In eight the return is stated to have 
occurred in distant parts—one in the liver, causing death 
eight years after the operation, and another seven years after. 
In the six other cases there was a return, either in the neigh- 
boring lymphatics or in the internal organs, at a time varying 
from one year to sixteen months. This gives a total of twenty- 
four cases, out of one hundred in which the result is known, 
in which life was prolonged from one to six years with no re- 8 
turn of the disease; three which proved fatal after six years; 
and six in which there had been no return ten years after the 
operation. On the other hand, deducting two cases stated to 
have proved fatal by a return of the disease, but at a time not 
given, and seven cases of Labbe’s in which the average time 
of return is said to have been ten months—in thirty-five cases 
where this fact is mentioned there was a local return in nine 
within three months, in nine within six months, in eleven 
within one year, in four within a year and a half, and in three 
within two years. 
But, to arrive at a just conclusion as to the value of the 
operation, we must study these figures in a different light. 
It is claimed in favor of lumbar colotomy that the operation 
of excision, even when a good immediate result is obtained, 
may shorten life by hastening the return and final progress 
of the disease. Unfortunately 7, it is difficult to tell in any 
particular case how long a patient would have lived, had the 
disease been left to its coui’se; but, accepting as a basis for 
comparison Allingham’s estimate of the average duration of 
life in cancer of the rectum as two years or less, we are justi- 
fied in concluding that in all cases where life was prolonged 
more than one year and a half after the time of operation 
(the operation generally being done late in the disease), this 
length of life may fairly be attributed to the surgical inter- 
ference. We find, not counting the permanent cures above 
stated, twenty-two such cases. 
This estimate is manifestly a small one, for a study of the 
cases makes it evident that many who did not live eighteen 
months after the operation yet gained a considerable length 
of comfortable existence; and there is nothing to prove that 
in any case the operation hastened the natural course of the 
disease. We can only guess in any given case what the dura- 
tion of life would have been had the disease not been inter- 
fered with, and, in cases where the estimate has exceeded the 
reality, it still remains to be proved that the operation is to- 
be held accountable. There is a marked absence of anything 
in the reported cases which would go to uphold this supposi- 
tion. On the contraiy, we find in almost every case that at- 
tention is called to the great improvement in general health,. 9 
the loss of pain, and the increase in strength. Patients go 
away believing themselves radically cured, return to their 
employments, and are reported by the French surgeons as 
“parfaitement gueries,” a few weeks after the operation. 
And this leads me to call attention to another point—the 
operation of excision as a palliative measure. In cases prop- 
erly chosen, where the disease is not so extensive as to render 
its removal one of the capital surgical operations, we know of 
nothing better, and this fact can not fail to be deeply im- 
pressed upon the reader of these cases. The statement that 
all suffering was relieved is almost invariable. 
I have carefully searched the record of cases in which a 
return of the disease within six months of the time of opera- 
tion is reported, to discover whether, here also, there was any 
marked relation between this result and the nature or extent 
of the disease at the time of operation ; but it is especially at 
this point that the table fails us. A proper answrer to this 
question involves not only a careful 2’eport of the extent of the 
disease, but a microscopic study of its character, and such data 
are given only in a relatively small proportion of cases. I 
believe, however, that the cases show a marked relation be- 
tween the rapidity of the growth before operation and the 
speedy return after removal. 
We can trace no connection between the time of the re- 
turn and the extent of the disease removed when the removal 
has been complete; and the microscopic reports are too few 
for general conclusions to be drawn from them. I know of 
no writers, except Stimson and Holmer, who have made a 
careful study of the specimens excised, and have given the 
results; and, so far as the clinical reports of the German 
operators go, they would seem to give support to their prac- 
tice of removing everything involved, no matter how exten- 
sive, in the hope that the local return may be long delayed. 
One other point which has been held to weigh against this 
operation is the alleged incontinence of faeces sure to follow 
it. In studying these cases, it strikes one curiously to read in 
Gross’s “ Surgery ” that this result is sure to follow excision of 
a portion of the rectum sooner or later. In forty-live cases in 
which the condition in this respect is noted, there is stated to 10 
have been complete control over the evacuations in seventeen, 
control except in case of diarrhoea in nine, a fair amount of 
control (enough to prevent accidents, provided the patient 
were able to attend to the call of nature as soon as it was felt) 
in ten, and complete incontinence in nine only. 
Admitting the fact, how can it be accounted for? For 
my own part, I have studied this question till I find it much 
easier to prove that there should not be incontinence after de- 
struction of the sphincters than to explain why there should be. 
I believe the sphincters play a very secondary role in the phys- 
iology of defecation, and yet a great degree of incontinence 
has been seen to follow their simple division in cases of fistula. 
The anatomical arrangement which was first described by 
ISTelaton under the name of a “third sphincter,” and which is 
supposed to take the place of the others, is not all a myth, 
neither is it what its name would indicate to one having in 
mind the muscular band closing the anus; and Houston’s 
folds of mucous membrane, though sometimes heavy enough 
to obstruct the passage of faeces, can not be relied upon. In 
the reports of cases there are many in which it is stated that 
the patients were able to live comfortably by giving immedi- 
ate attention to the desire to evacuate; and it is perhaps the 
power to resist a desire to evacuate the bowels, rather than a 
constant resistance to the passage of faeces which have accumu- 
lated in the rectum, which best expresses the function of the 
sphincters in defecation. 
The periodically recurring descent of fieces into the rectum 
causes the desire to evacuate. In health, we are able to resist 
that desire, and after a certain time it may pass away and 
may not return till a corresponding hour of the succeeding 
day. Its passing away is probably due to the retreat of the 
feces into the sigmoid flexure. When the sphincter is de- 
stroyed, we still have the warning of the descent of feces, but 
the power of control or resistance after such descent is gone. 
This is emphatically coming back to O’Beirne’s “new 
views of the process of defecation ”; but the views which he 
published in 1833 are essentially those which Foster publishes 
in 1880, and they are founded on the facts (?) that the rectum 
is normally empty, and that, except in cases of chronic con- 11 
stipation, where the rectum has become unnaturally distended, 
no feces will be found pressing against the sphincter or below 
the sigmoid flexure. 
The feces, as they pass along the colon, are lodged for a 
time in the sacculi, and finally accumulate in the sigmoid 
flexure, where they are supported by the sacrum and perhaps 
also by the bladder. Defecation is the result of a voluntary 
effort at first, but yet is actually accomplished by a mechanism 
heyond the control of the will. The voluntary part of the act 
is shown in two ways; first by inhibiting the action of the 
lumbar nerve center which controls the sphincter, and thus 
relaxing its normal tonic contraction ; and secondly, by the 
voluntary pressure on the colon by the abdominal muscles. 
But neither of these is sufficient to empty the sigmoid flexure, 
and they are therefore joined to a third involuntary element 
in the act—an increase in the peristaltic movements of the 
flexure itself. This, however, is not exactly the order of action. 
The sigmoid flexure becomes full, and the pressure of the 
feces excites in it an increased peristaltic action, by which its 
contents are pressed onward into the previously empty rectum 
and come to press upon the sphincter. The sphincter is then 
relaxed by the voluntary inhibiting of its spinal nerve center, 
and the pressure of the abdominal muscles is brought to bear 
upon the descending colon; by which, and by the increased 
peristalsis, the sigmoid flexure and the rectum are entirely 
emptied. 
Accepting these views of the physiology of defecation, it 
is not difficult to understand why there should not be com- 
plete incontinence after destruction of more or less of the 
lower end of the rectum and anus ; and there are other facts, 
such as the presence of the valves, the crooked course of the 
rectum, and its normal contraction due to its heavy muscular 
layer, the consistence of the faecal mass itself, and its tendency 
to lie quietly in its place till expelled by the activity of the 
involuntary muscular fiber of the gut, which tend to the 
same result. The question admits of much discussion, but 
the fact remains, that, as a palliative measure, lumbar colotomy 
has no advantages over excision on the ground of comfort and 
cleanliness. 12 
From a study of the cases we are justified, then, in draw 
ing the following conclusions : 
1. The fatal results which have thus far been recorded as 
following this operation nearly all occurred in cases where 
from the extent of the disease such a result was not improb- 
able. 
2. When the disease reaches above three inches, or in- 
volves neighboring parts to such an extent as to render its. 
entire removal without injury to the peritonaeum question- 
able, the operation is contra-indicated. 
3. Although there have been a few cases of cure, such a 
result is so rare as not to justify the exposure of the patient 
to the risk of immediate death which attends the attempt to 
remove extensive cancerous disease. 
4. The operation is chiefly valuable as a palliative measure, 
and as such it is applicable to cases where the disease has not 
made extensive progress. 
5. As a palliative measure in proper cases, it compares 
favorably with the results of lumbar colotomy, both in pro- 
longing life and in relieving pain. 
6. The operation is not followed by an annoying incon- 
tinence of faeces, except in a small proportion of cases. 
7. The operation is not a substitute for lumbar colotomy 
in cases where the disease has reached more than three inches 
from the anus. 
8. There is no proof that the operative interference short- 
ens life by hastening the progress of the disease. 
Agnew.—“ Phil. Med. Times,” June 23, 1877. 
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Briddon.—“Med. Record,” Jan. 6, 1877. 
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294. 
Byrne.—“ Annals of the Anat. and Surg. Soc.,” May, 1880. 
Baumes.—“Bull, de I’Acad. Roy. de Med.,” t. x, p. 936. 
Chassaignac.—“Traits de I’ecrasement lineaire,” Paris, 1856. 
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Crosse (quoted by Mayo).—“ Observations on Diseases and Injuries 
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BIBLIOGEAPHY. 13 
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Stimson.—“Arch, of Med.,” Aug., 1879. 14 
Terrillon.—These de Oarcopino, 1879. 
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vol. iv, p. 814. 
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tr6rnite luf6rieure du Rectum.” 
Yolkmann.—“Klin. Yortrage,” March 13, 1880.