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The patient was put to bed with the trunk elevated, as recommended by Bardenheuer,' to favor drainage, and hot bottles were put around him. The operation lasted three hours. The temperature, save once, never rose above 101°, and the urine needed drawing only for three days. On the third day, the bowels were moved on account of flatulence. The patient had no pain and continued to improve from the first. The stitches and tube were removed on the eighth day, and good union was found of all save the posterior quarter of the bowel, where the strain had cut through the stitches. More than two months have elapsed since the operation. The patient has a normal appetite, absolutely no pain, can walk a mile or more, and has gained in flesh and feels much better than for two years preceding the operation.
The wound is now well healed, there is no evidence of recurrence, and the only inconvenience is the incontinence of fæces, which results in five or six movements a day, without warning. However, this incontinence seems to be improving as the wound contracts. Microscopic examination of the excised portion of the bowel showed the growth to be a cylindrical epithelioma. In the ulcerated portions of the growth, all traces of follicles were absent, and the morbid tissue showed an alveolar structure in which were large masses of cylindrical epithelial cells, many of which in their arrangement closely resembled adenoid tissue. In most places the reticulated tissue appeared to be made up of epithelium. In the less involved portion of the bowel, at each limit of the growth, there was infiltration of the follicular and submucous tissue with small, round cells, and in the submucous layer were occasional masses of cylindrical epithelium with gland-like arrangement. The upper limit of the excised portion was apparently healthy. I expect the propriety of the operation will be questioned, and that many will claim that as good if not better results could have been obtained by colotomy or linear rectotomy. Still, from the latter view I must dissent. Modern pathologists quite universally agree that cancer is primarily local; and the results obtained in radical antiseptic operations for removal of cancer of the mamma,
1 "Zur Frage der Drainirung der Peritonealhöhle," Stuttgart, 1880.
uterus, and rectum would seem to bear out this proposition. So long as our means of controlling the accidents of excision (hæmorrhage and cellular inflammation) were defective, it is not surprising that colotomy and other temporizing methods were preferred. But now that the means of controlling hæmorrhage in long operations are so perfect, and the measures for controlling infection during and after the operation are so good, the question of the relative value of colotomy and excision of the rectum needs to be studied anew, notwithstanding, the brilliant papers of Esmarch and Bryant at Copenhagen. Believing in the local origin of cancer and its slow infecting tendency in many cases, Bardenheuer1 declares that there are no contraindications to excision of the cancerous rectum, save immobility of the growth by reason of its size or attachments to the pelvis. Mere linear extent, necessitating the opening of the peritoneum, is, according to Volkmann, Esmarch, and Bardenheuer, no contra-indication. Bardenheuer successfully removed the rectum where the upper limits of the excised portion measured nine and thirten inches from the anus. Volkmann's incision, used in my operation, seems to give plenty of room without removing the coccyx, as is advised by some. When contra-indicated by the immobility of the tumor, excision of the rectum must give place to some form of colotomy, and here again I think modern antiseptic methods will decide eventually for an abdominal rather than a loin incision, with probably the modification suggested by Madeling, of Rostock, of completely severing the bowel and closing the lower severed end with sutures. When we consider the horrible sufferings entailed by cancer of the rectum, and the early age at which many are attacked (a case in a lad of seventeen years came under my observation when house-surgeon in the Boston City Hospital), an operation which promises, in some cases, according to its advocates, immunities of from four to eleven years, at only the expense of more or less incontinence of fæces, deserves a wider acceptance at the hands of the English-speaking world than it has heretofore received. In fact, the cases mentioned by Volkmann and Es
1 "Drain. der Peritonealhöhle," Stuttgart, 1880, p. 11.
march of non-recurrence and comfort for four, six, eight, and eleven years should be regarded as cures, and are encouraging to all who seek to mitigate the horrible sufferings of the cancerous subject. We do not give up hope in cancer of the breast; why should we in cancer of the rectum? As to the incontinence, it is common both to colotomy and excision, with the advantage of ease in maintaining cleanliness and the natural site of the artificial anus in favor of excision.
DOUBLE SYNCHRONOUS AMPUTATIONS.
By U. C. LYNDE, M. D., of Erie County.
It has been my object to secure a report of all the grave operations known as double synchronous amputations, by whomsoever made, in this State. I shared with many others the conviction that there would be an innate reluctance on the part of operators in general to report unfavorable results; and I consequently wrote, not only to those who were operating surgeons, but to nearly the whole profession, except in the great cities of Brooklyn and New York where I relied, in the main, upon hospital reports. However, I directed some five hundred letters to members of the profession in these two cities. The text of these letters was as follows:
BUFFALO, N. Y., February 25, 1884.
DEAR DOCTOR: Will you write me if in your town or vicinity any double synchronous amputations through forearm, elbow, arm, shoulder, leg, knee, or thigh, have been made by yourself or others; and, if so, for what cause, and with what result; giving name in full of parties on whom the amputations were made; also, their present residence, if known to you, and oblige,
U. C. LYNDE, M. D., 7 Fitch Building.
By this it will be seen that it was my aim to find out all the cases that had been operated upon, those that had proved successful and those that had not. On the subject of single amputations, our treatises on general surgery have given us very full statistics, from the operations made by military surgeons, and also those made in the hospitals of Europe; to which can be added those reported in more recent works, as having been
made in the hospitals of our own country, especially those of Philadelphia, New York, and Boston. Statistics have been handed down to us, in some cases for a century; and if they are not what we need at the present day to aid us in our practice, they are certainly not devoid of interest as showing the results of the amputations in past times. I am not aware of any effort having been made in the way of statistics to find out the results of amputations in private practice. Concerning amputations in general, the task would be difficult, and the results, when made, would be unreliable. In securing and preparing for this paper the cases reported by different surgeons throughout the State, little heed has been paid to time, labor, or expense. Grave and important cases have been accepted only upon an abundance of disinterested evidence; evidence often not only of active competitors, but even of enemies in the profession. In some cases that seemed doubtful, or rather admitted of a doubt, I have either written, again and again, to members of the profession living in the particular vicinity or to citizens outside of the profession in the same town. In some instances I visited the places myself. In the cases that have been investigated, conclusive proof has not been wanting of their truthfulness. In concluding this subject, I must acknowledge that not a false report of any case has been sent to me. Except in the great cities of Brooklyn and New York, it is doubtful if many cases have eluded search; and, even in these cities, it is not probable that many have been missed. Considering their size, they are not cities affording many cases requiring these operations. Hospital reports in this State bearing upon these amputations are unreliable. As only three cases have been ferreted out in the hospitals of Buffalo, I am unwilling to give them to the profession, except under protest. That these are the only operations of this character that have been made at the hospitals in this great railway-city, is barely possible, but is not probable. The cases reported as having been operated upon in private practice in Buffalo probably include all for the last half century. In cities like Rochester, Albany, Syracuse, and Troy, letters were addressed to every member of