CASE OF CANCEROUS STRICTURE OF THE RECTUM, PRODUCING OBSTRUCTION, SUCCESSFULLY RELIEVED BY COLOTOMY

T CURLING
1870 The Lancet  
aged forty-eight, a tall, hale-looking man, a market-gardener, was brought to me by Mr. C. Thompson, of Westerham, on March 13th, 1868, on account of obstruction in the lower bowel. It appeared that he had been subject to relaxed bowels for three or four years, and that he had not passed a formed motion during that period. He had voided bloody mucus occasionally. His bowels having been confined for several days, he was induced to take some black draughts and large doses of castor-oil. They
more » ... stor-oil. They produced no evacuations, but caused vomiting, and he then sent for Mr. Thompson, who allayed the sickness with opium. He passed afterwards a very small quantity of liquid feculent matter. When I saw him, obstruction had existed for twelve days. His tongue was loaded, and he had lost all appetite. His pulse was tolerably firm. His abdomen was enlarged, but not extremely distended, and there was no pain on pressure in any part. On digital examination of the rectum, I detected, as high up as the finger could reach, a mass of induration, with a close irregular aperture, indicating a cancerous stricture. I had no hesitation in recommending colotomy to relieve the obstruction, and to retard the progress of the cancerous disease. On the 15th, I went down to Westerham, and performed the operation. Since the 13th, about half a pint of liquid feculent matter had escaped from the rectum, but the distension of the abdomen was increased. Chloroform was given, and the colon was found without difficulty. Not an ounce of blood was lost in the operation. Liquid feculent matter passed freely from the opening in the colon in the course of the day. I did not see this patient again, but received reports of his subsequent progress from Mr. Thompson. In a letter dated March 19th, 1869, more than a year afterwards, he states: 11 The colotomy has answered its purpose admirably in Mr. C-'s case. There has been no trouble in getting free evacuation of the bowel, and matters have been so well managed that really there has been little or no unpleasantness. He has worn generally a pad-a piece of sponge covered with oil silk,-or a large bone nipple shield immediately over the false anus, covered with a small square of I spongio-piline, slightly wetted with carbolic-acid lotion, the whole being kept in place by a stout belt. The bowels have generally emptied themselves once a day, and the rest of the time there has been no inconvenience. He has suffered a good deal from tenesmus, and discharges of blood-stained mucus from the rectum; but I control this, and the pains which at times are severe all over the pelvic region, with suppositories of opium. He is now using about four grains a day. He is getting slowly weaker, but his life is very tolerable." . Our patient lived till the 12th of August, having sur-, vived the operation seventeen months. Mr. Thompson writes thus :-He had been gradually sinking for some months, and the end was caused by the sudden loss of a considerable quantity of blood from the rectum. He suffered very much latterly from attacks of violent neuralgic pains,with spasms of the muscles of both thighs, and occasionally had attacks of convulsive spasms of the muscles of the arms and neck. To relieve these, I was accustomed to give morphia subcutaneously, and at last the large dose of three grains and a half was thus administered twice daily without producing narcotism. Besides this, the rectum was so irritable that he had four grains of opium introduced in suppositories twice daily, and he was most uncomfortable if they were omitted. " Mr. Thompson examined the body, and noticed how little it was emaciated. He found the shrunken colon healthy for about four inches below the false anus. He could not get the tip of his finger below the sigmoid flexure. A mass of hard cancer blocked it completely, and seemed to have I obliterated the several structures. It invaded the posterior wall of the pelvis, sacral plexus, &c., accounting for the pains the patient had suffered. The other viscera appeared healthy, but the examination was hurried. A large tumour had formed at the right elbow, which seemed to be a deposit of soft cancer in the upper part of the radius, distending the bone. This case is deserving of record, as showing the great advantage of colotomy in cancer of the rectum. The patient was not only rescued from impending ueath from obstruction, and survived the operation seventeen months, but, as Mr. Thompson's reports show, he lived in tolerable comfort for twelve months, when the advance of the disease gave rise to considerable suffering, which required unusually large doses of morphia for its relief. It was fortunate for the patient that colotomy was required at a comparatively early period of the disease; for it is only when the operation is performed early that we can hope to retard the progress of cancer, and to prevent the frequent painful defecation which is generally so distressing in these cases. In a recent discussion at the Clinical Society, Mr. Erichsen is reported to have said " that the great relief afforded by colotomy in cancer had been demonstrated in Paris as elsewhere." The credit of having first suggested the operation to retard the progress of scirrhous disease of the rectum and large intestine, and to prolong life, is justly due to Amussat; but his memoirs on the operation, which I presume include all the cases in which he had performed it, contain no case in which it was done without the existence of obstruction-merely to relieve the sufferings of cancer; and what is remarkable, the French surgeons do not seem to have appreciated the advantages of the operation for this purpose. I know of no published case in which colotomy has been performed in Paris except to relieve obstruction.
doi:10.1016/s0140-6736(02)31271-6 fatcat:lw3bq7t67nhqhifofzzo3kb5zi