Five Years' Work in Diseases 
of the Rectum 
At the New York Post-Graduate Hospital. 
BY 
CHARLES B. KELSEY, M.D. 
REPRINTED FROM THE 
Neto York j^ehical Scurnal 
for December 8, ISDf Reprinted from the New York Medical Journal 
for December 8, 18V f 
FIVE YEARS' WORK 
IN DISEASES OF THE RECTUM 
AT THE NEW YORK POST-GRADUATE HOSPITAL. 
By CHARLES B. KEtSEY, M. D. 
The total number of cases treated lias been seven hun- 
dred and ninety-six. These are divided as follows: 
Haemorrhoids, 267 ; fistula, 107 ; non-malignant ulceration 
and stricture, 84; fissure, 55 ; cancer, 49 ; pruritus, 42; 
prolapse, 35 ; abscess, 34 ; polypus, 20 ; malformations, 6 ; 
pelvic abscess, 8 ; faecal incontinence, 7. The remainder 
includes all the various forms of disease which find their 
way to such a clinic, from uterine disease to chronic con- 
stipation. 
The operations before the class have been as follows: 
Haemorrhoids, 137; fistula, 63; fissure, 33; abscess, 23; 
colotomy, 40; extirpation, 24; ulcers, 25; prolapse, 25; 
polypus, 15 ; pruritus, 9 ; proctotomy for stricture, 8; faecal 
incontinence, 5 ; proctocele and cervix uteri, 5 ; intussus- 
ception, 1 ; pelvic abscess, 3 ; congenital malformations, 
3 ; recto-vaginal fistula, 1 ; total, 418. 
Leaving all of the minor cases with the simple state- 
ment that all haemorrhoids are still operated upon by the 
Copyright, 1894, by D. Appleton and Company. 2 
FIVE YEARS' WORK IN 
clamp and cautery method because we have yet to find any 
other plan we like as well, and that we are still waiting to 
see any of the bad results which Allingham asserts are in- 
separable from this method, or any of the failures to cure 
which Whitehead says can not possibly be avoided, we 
pass at once to the consideration of the cases of stricture 
and incurable ulceration, for the study of which the clinic 
has thus far offered such exceptional advantages. 
Of these we have shown and examined ninety-nine. 
Forty-nine have been malignant and fifty non malignant. 
Sixty-four have been in males and thirty-five in females. 
In the last year's report attention was called to the fact 
that our experience here did not support the usually ac- 
cepted statement that this disease was nearly twice as com- 
mon in females as in males ; and this fact becomes still 
more noticeable as the number of cases increases. 
As to the nature of the non-malignant cases, four were 
of dysenteric origin. In them, as a rule, the amount of 
ulceration is far in excess of the amount of contraction. 
There is distinct stricture, it is true, but the symptoms of 
that condition are not as prominent as the discharge of 
pus and bloody mucus, the tenesmus and wasting away 
which characterize the ulceration. 
Six were congenital and six were due to pressure from 
without or obliteration of the gut from diseases not pri- 
marily of the gut itself. One was distinctly tubercular in 
character. This leaves thirty-three out of fifty to be ac- 
counted for, and all of these are of the kind generally in- 
cluded under the head of syphilitic, although in only six of 
them was there any syphilitic history, and in only a single 
case am I convinced that syphilis had anything to do with 
the pathology. That particular case was a child suffering 
from well-marked estheom'ene or lupus. For a time she im- 
proved greatly under specific treatment, though a few weeks DISEASES OF THE RECTUM. 
3 
ago her physician told me the improvement had ceased and 
the disease had taken on the usual incurable character. 
Instead of attributing the thirty-two other cases to 
syphilis and to some pathological process of which we 
know nothing connected with that disease, I prefer to con 
sider them the result of a simple proctitis, proliferating 
and contracting in its results, which may be set up by any 
local injury to the part, and which, once having passed the 
early stages, is practically incurable. Anything which 
causes an abrasion of the mucous membrane may cause a 
stricture of this variety if the abrasion goes on to ulcera- 
tion and the ulceration is not cured by proper local treat- 
ment. 
Again and again we have this history forced upon our 
attention, and it will in time be allowed its proper weight 
with all those who are not so overawed by the mass of au- 
thority in favor of the syphilitic idea that evidence to the 
contrary has no influence upon them. Constipation and 
faecal impaction, surgical operations, injury to the rectum 
in childbirth are some of the everyday causes of the so- 
called syphilitic stricture, both in those who have had and 
those wdio have not had syphilis. Every practitioner has 
seen these simple lesions cause stricture of the rectum a 
few years later if he has watched the development of his 
cases. How many men have ever seen syphilis cause stric- 
ture ? I do not mean how many have seen well-developed 
strictures and have jumped to the conclusion that they were 
syphilitic. Where in the body do we find any analogous 
syphilitic process ? Neither in the air-passages nor the 
oesophagus, for here when we find syphilitic stricture we 
find contraction from cicatrices resulting from syphilitic 
ulceration. The deposit which causes stricture in the rec- 
tum is not gummatous either under the microscope or in 
its clinical history, and the name ano-rectal syphiloma, 4 
FIVE YEARS' WORK IN 
which has covered it as an all sufficient explanation for 
years, has come to express nothing. 
The writer does not wish to be misunderstood in this 
matter. 
Syphilis may cause a stricture of the rectum by caus- 
ing an ulceration of the mucous membrane exactly as a 
surgical injury or a scybalous mass may do, and in no other 
way. I have seen such syphilitic ulceration, and had it 
not promptly yielded to local and specific treatment I have 
no doubt that it would have caused a stricture exactly as it 
would have done in the oesophagus. 
That syphilis has any connection or relation with stric- 
ture of the rectum except in this way we have no particle 
of proof. That the so-called syphilitic stricture, both in 
syphilitic and non-syphilitic patients, may be caused by 
any local injury we have daily evidence. 
Of these ninety-nine strictures, forty have been treated 
by colotomy, twenty-four by extirpation, and eight by di- 
vision. 
Of the forty colotomies three have died. This state- 
ment left without explanation would give a very exag- 
gerated idea of the mortality of the operation. Only one 
of the deaths was in any way due to the operation, and 
that one was a pure accident, and might easily have been 
avoided-indeed, should have been. 
The first death was caused as follows: The patient, a 
woman, was in the midst of complete intestinal obstruction 
from cancerous disease. The pelvis and abdomen were 
full of cancerous masses, and after the incision was made it 
was with some difficulty that a healthy piece of sigmoid 
flexure and mesentery could be found in which to make the 
opening. After thirty-six hours the patient had a chill 
and high temperature and the symptoms of shock. The 
gut was opened, the parts found in good condition, but the DISEASES OF THE RECTUM. 
5 
opening of the bowel gave no relief, nor did any quantity 
of gas or faeces escape, which, considering the distended 
state of the abdomen, was considered remarkable. Death 
followed in a few hours, and upon autopsy the obstruction 
was found to be unrelieved. A cancerous nodule existed 
at the splenic flexure of the colon, which had almost com- 
pletely closed the caliber. Against this there was pressing 
a small, hard faecal mass acting as a perfect ball valve, 
which had caused death. 
The second death was in no way due to the operation. 
The case was one of acute phlegmonous periproctitis fol- 
lowing the division of a stricture. After the patient was 
exhausted by the disease and at the point of death a com- 
munication formed between the rectum and bladder. To 
do away with this additional cause of danger a colotomy 
was performed, but without retarding the inevitable result 
of the disease. 
We then had a run of twenty-four successive cases with- 
out accident, and the next and last death was directly due 
to the operation. 
The patient, as usual suffering from cancer, was in ex- 
cellent condition and a favorable prognosis was given. On 
the second night after the operation the bandages were 
found soaked in serum, which had wet them through and 
was soaking into the bed. All night the patient was al- 
lowed to remain in this condition before the wound was 
examined, and I was sent for. Then it was found that 
many feet of small gut had escaped through the incision 
and were lying under the dressings. The gut was partially 
strangulated, deeply congested, all of the coils were matted 
together by plastic exudation, and the dressing of gauze 
was so firmly adherent to the protruding mass that an hour's 
careful dissection was necessary for its removal. By the 
time the parts had been replaced the patient was in a con- 6 
FIVE YEARS' WORK IN 
dition of fatal shock. This is the only case of colotomy, 
either in private or hospital practice, in which I consider 
that death could fairly be attributed to the operation. In 
private practice in two or three cases death has not been 
delayed by the operation, but in none has it been hastened. 
I report this case fully as a warning. The same acci 
dent has happened before and may again, but it should 
never be a fatal one, and would not be if discovered early 
and properly managed. Sudden and profuse discharge of 
a large amount of serum from the abdomen after colotomy 
is a sign that some part of the wound has given way, and 
should lead to immediate removal of the dressings for in- 
spection. If hernia be found, it is an easy matter to re- 
duce it, and a stitch or two in the wound will keep it re- 
duced. 
From the twenty-four operations for extirpation of the 
rectum there have been seven deaths. 
The more experience we have with this operation the 
more convinced are we that the rate of mortality depends 
chiefly upon the technique. Of course, the cases for op- 
eration must be carefully chosen. In non-malignant stric- 
ture the extent of the disease is seldom or never such as to 
contraindicate extirpation. In cancer the disease must be 
movable. In other words, no matter what its distance 
from the anus and no matter what length of gut is in- 
volved, the disease must be confined to the gut, and must 
not have invaded adjacent parts, otherwise attempt at re- 
moval is unjustifiable. 
The comparison of these statistics with those of other 
operators is difficult because of the absence of details in the 
published reports. My own cases are simply twenty-four 
consecutive ones, in all of which it seemed possible before 
commencing to completely remove the disease, and the 
mortality is about that of the German clinics. Had the DISEASES OE THE RECTUM. 
7 
severe cases been subjected to colotomy and the mild ones 
extirpated the mortality would have been less and the re- 
currences also less. It would be possible to do the opera- 
tion twenty-four times without any mortality and with few 
or no recurrences within the limit of five years, but the 
cases would need to be carefully selected ones of epithe 
lioma confined to a small portion of the gut and removed 
early. 
My own experience has taught me rather to expect re- 
covery without serious accident in a clean and antiseptic 
Kraske's operation when the upper end of the gut is well 
vitalized at the point of section and is brought out behind 
and stitched to the skin at the part left vacant by the re- 
moval of the end of the sacrum. Union soon takes place ; 
faeces escape on the surface of the body and do not con- 
taminate the wound, which may be expected to heal in 
part by primary union ; and the patient makes a rapid re- 
covery without high temperature. 
This operation is, however, not the ideal one. The dis- 
ease is removed, it is true, and the great object of operat- 
ing is thus accomplished ; but the after condition of the 
patient is not as good as after a colotomy. 
It may be safely asserted that if a patient is to have an 
artificial anus anywhere, the best place for it is in the left 
inguinal region and not over the sacrum. 
One great element in the mortality at this clinic has 
been the repeated attempts not only to remove the disease, 
but to put the parts in the same condition as before the 
operation, by uniting the divided ends of the gut and re- 
placing the trap door formed by cutting across the sacrum. 
When we fail in the attempt to get immediate union of the 
ends of the gut the wound becomes fouled with faeces, 
there is suppuration, great exhaustion, and prolonged high 
temperature, and the patient barely escapes with life. 8 
FIVE YEARS' WORK Iff 
Attempt at immediate union of the ends of the gut 
should never be made unless the upper end be well vital- 
ized and well supplied with mesentery. Where the disease 
has involved the upper rectum, and where after opening 
the peritonaeum it has been necessary to dissect off and 
divide the mesorectum to a considerable extent to bring 
the gut down, it will often be found that when the gut is 
finally cut across above the disease all precautions against 
bleeding from the proximal end are unnecessary. The cir- 
culation has been so interfered with by ligatures placed 
upon the mesentery that the cut surface has not sufficient 
blood supply to bleed. Or, in non-malignant stricture, 
when the same section is made above the constriction the 
proximal end will be found infiltrated, lardaceous, grayish 
in color, and with few vessels. It is not to be expected in 
such cases that good union will take place between this 
end and the anal portion, no matter what particular form of 
apposition is effected, and the proximal end under these 
circumstances should simply be turned out behind and su- 
tured to the skin, care being taken if possible to cut off 
enough so that healthy gut is reached without too great 
traction. 
This condition has more than once prevented our doing 
what is so well advised by Gerster-twisting the gut to 
prevent incontinence. We have feared to still further ob- 
struct a very feeble blood supply. 
It being decided that an attempt at uniting the ends of 
the gut is justifiable, we have the choice of three ways-the 
Murphy button, end-to-end suture, and suture after invagi- 
nation of the upper into the anal extremity. The proper 
application of the button requires that a considerable por- 
tion of the anal end of the gut has been left after removal 
of the stricture. It is also to be remembered that there is' 
no peritoneal covering to the ends of the gut which assists DISEASES OF THE RECTUM. 
9 
so greatly in union within the peritoneal cavity. For this 
reason the ends should be well scarified where they are to 
come into contact when the halves of the button are pressed 
together, and the union should be further strengthened by 
a row of sutures. 
In spite of all this one of our own fatal cases was due 
to sloughing of the upper end and extravasation of fieces 
into the wound. 
Between end to end suture and suture after invagi- 
nation the operator may choose for himself. The lat- 
ter is much quicker and easier. Both will occasionally 
succeed and often fail, and when they fail a life will per- 
haps be lost which might have been saved for a time by 
the simpler operation of bringing the upper end of the 
gut out behind. 
I am convinced that it is in great measure upon these 
points in technique as well as upon the selection of the 
cases that the mortality of the operation at present de- 
pends ; and that the success and failures of the future will 
depend upon the results of careful practice and experiment 
along this line. 
One other practical point has been forced upon the 
writer's attention. 
In cancer of the rectum any kind of anus which may 
result is justifiable and desirable provided the growth can 
be removed. But in non-malignant stricture, as it often 
presents itself, especially in the old cases of so-called syphi- 
litic stricture, the future of the operation of excision de- 
pends entirely upon the ability not only to remove the 
disease but to put the parts after the operation in some- 
thing like the natural condition. 
I do not contend for perfect fsecal control, for the pa- 
tients do not have that before the operation; but they 
must at least be left better oft' after the operation than be- 10 
DISEASES OF THE RECTUM. 
fore it, and better off than they would be after colotomy to 
compensate for the great additional risk of one operation 
over the other. 
It is a difficult matter to choose between the compara- 
tive discomforts of an average case of old stricture; the 
condition following extirpation, where the gut is brought 
out over the sacrum or the patient is left with two open- 
ings, both discharging faeces, one the natural one and the 
other somewhere else near it, generally called a faecal fistula ; 
and the condition following colotomy. Unless the condi- 
tions following extirpation in these cases can be made 
much better than those which follow colotomy, the opera- 
tion will soon be crowded aside and we shall return to 
where we were a few years ago, with the only choice be- 
tween colotomy, on the one hand, and proctotomy or dila- 
tation on the other. 
There is certainly no operation connected with the sur- 
gery of the rectum in which practice and skillful technique 
have so great a bearing upon the results. The New York Medical Journal. 
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