The removal of the rectum is an important subject, as it is one of the achievements of modern surgery. Extirpation of the rectum is a child of modern surgery, inasmuch as it was not until iodoform gauze was used for packing and drainage that it became devoid of its dangers. In former times it had such an appalling mortality that colotomy was preferred by the English surgeons, and the removal of the rectum regarded as an almost not permissible operation.

Volkmann made the first step toward utilizing antiseptic principles and reduced the death rate, but his method of drainage with permanent irrigation was cumbersome, complicated, and often, in cases where the peritoneal cavity had to be opened, dangerous. I have seen in such a case the abdominal cavity filled with more than two gallons of carbolic acid solution; thus it was not until the advent of iodoform gauze that a radical change came about. I have paid a good deal of attention to these operations, inasmuch as I have extirpated the rectum sixteen times, eleven times for carcinoma and five times for inflammatory stricture. As far as carcinomas are concerned I will in this connection present two specimens, the one illustrating a low carcinoma, as I prefer to call it, a carcinoma. that involves the sphincter; and one a high carcinoma, that is a carcinoma that has left the sphincter and a couple of inches of the rectum intact. The first specimen is a low carcinoma, consequently the anus is there. The carcinoma, as may be seen, takes in the anus and about three inches of the rectum, and behind it there is a mass of adipose tissue from the concavity of the sacrum, in which we see a tumor the size of a walnut, which is a carcinomatous para-rectal lymphgland. It is always advisable to remove this tissue just the same as to remove the axillary glands when a carcinoma of the mamma is operated upon, or the submaxillary glands when operating for carcinoma of the lips, because this is the place where the carcinoma first extends outside of the rectum to the lymph glands in the surrounding tissues.

The other specimen is what we might term high carcinoma, inasmuch as the anus and lower portion of the rectum are left. As will

*Read before the Chicago Medical Society, May 20, 1889.

CHICAGO:

G. P. ENGELHARD & CO

be seen, there is a ring-shaped carcinomatous tumor two and a half inches long occupying the entire circumference of the gut, ulcerated on the nodular surface, making a constriction which hardly permits the passage of the little finger. At the upper and lower part of this ring is three-quarters of an inch of healthy wall of the rectum transversely divided, thus showing that the anus with the sphincter has been left.

As to the method of operating, I want to distinguish between the operation for low and high carcinoma. Low carcinoma includes the anus and will seldom if ever go up so high that there will be necessity for any more preparatory operating than to remove the coccyx; very rarely, with a view of getting more operating room it may be necessary to resort to the next step in the higher operation, namely, division of the left sacro-sciatic ligament, which gives a good deal more room.

In the operation of high carcinoma the next step in getting access to the rectum is to remove the left half of the sacrum, as proposed by Kraske, or even to remove it entire transversely on the line of the third foramen, with subsequent replacement in situ. This latter way of getting operating space I have tried once and found satisfactory; the patient survived the operation and died six weeks later from causes independent of it, after everything around the rectum had healed satisfactorily.

The two operations, of which the one for low carcinoma might be termed extirpation or amputation (Holmen), the one for the high operation, resection (Volkmann), are of course entirely different, inasmuch as the former commences at the anus, extending from there upward, and the other commences above and behind the anus and is really a posterior operation in the sacral region. The reason for distinguishing between the two operations, besides the entirely different technique, is also the difference in gravity of the operation. This means a different gravity of the disease, namely, that a high carcinoma is much more serious than a low carcinoma. Statistics which I got together a year ago in this respect showed eighteen high carcinomas with a mortality of fifty per cent., while a series of two hundred and seventy-two

operations for mixed high and low carcinomas showed a mortality of twenty-two per cent. In most of the statistics we meet with now no distinction is made between high and low carcinoma in the sense in which I wish to express it; that is the reason why the older mortality does not enable us to judge about a single case, inasmuch as it is too low for high carcinoma and too high for low carcinoma. Old statistics of Billroth showed a mortality of thirty-nine per cent.; more recent statistics of König showed a mortality of twenty four per cent. Quite recently Bramann published twenty-seven of Von Bergmann's cases with twenty-six recoveries and one death, that is 3.6 per cent. mortality.

As to the carcinomas I have operated on, in four high carcinomas, two men and two women, there were two deaths as the immediate consequence of the operation, and two recoveries from the operation, of which one died six weeks afterward, after everything around the anus had been healed. The second, the patient from whom this specimen was taken, is well, has gained twenty pounds in a few weeks, and is much improved by the operation.

For low carcinoma I have operated seven times, on six men and one woman, with four recoveries and three deaths, two of which were in immediate consequence of the operation. The third died from arterial hæmorrhage after four weeks.

A new field for extirpation of the rectum, or the low operation, was proposed by Israel in 1883, namely, to operate in this way for nonmalignant inflammatory strictures, whether due to syphilis or the gonococcus. This form of disease of the rectum will sometimes resist all other local measures, dilatation, division, etc., but will form peri-rectal abscesses and fistulæ, make life unbearable, and finally terminate in amyloid nephritis and death. In so intractable a case I have reason to believe that extirpation of the rectum is a decided success. I have done five extirpations for inflammatory stricture, on four women and one man, with no deaths.

In sixteen cases of this nature, reported by Israel, Busch, Riegner, Bardenheuer and myself, there were fifteen recoveries and one death, a mortality of about six per cent. The possibility of extirpation of the rectum for nonmalignant stricture of course depends upon the extent of the latter. It must be possible to reach reasonably healthy rectum above and draw it down. In the case of limited stricture, when the operation has been applied, all the authors agree that the patients have been decidedly benefited.

The advantage of the removal of such a strict

ure, if it is possible to get good healthy wall of the intestine, is that the disease is done away with at once. There are always foci of pus in the wall and the tissues surrounding such a rectum, and finally, around a stricture of this kind most irregular pus cavities form enormous pockets, which are of course done away with by the extirpation of the stricture when possible. When the stricture is above a certain point,then extirpation becomes impossible.

To return to the subject of discussion for tonight, the carcinomas: There are some points of importance in the operations which I shall now call attention to for instance, in operating for high carcinomas it is sometimes very difficult to bring the upper portion of the bowel down because the meso-rectum or lower portion of the mesentery of the sigmoid flexure may be unusually immovable. The mesentery must, of course, be divided until the bowel comes down. A good deal of dissecting may have to be done before the bowel can be brought down. In this respect I believe it is often possible to know beforehand about this difficulty, inasmuch as I think that the longer the stricture has existed, the easier the operation will be, because the efforts at defecation will make the upper portion more movable, and thus make the operation easier. It has often seemed to me also, when I came to a certain point in dissection, that then the upper bowel has come down easier; at the same time I have met with one case where it was almost impossible to get the upper intestine down. When united to the anus or lower portion of the rectum' there must be no tension at all, inasmuch as the sutures can seldom be kept aseptic, and thus are liable to tear through. The danger of tension is shown in a number of Kraske's cases, where in the same night of the operation the sutures gave way, the end of the upper bowel turned upward in an effort at defecation, which took place right into the peritoneal cavity. Kraske believes that preparatory treatment of such a patient to the extent of having the bowels entirely emptied might guard against such an accident, but I consider it rather doubtful whether any preparatory treatment can always guard against such a fatal defecation when rupture of the sutures takes place. I do not see how this can be absolutely guarded against, but the more movable the bowel and the more freely it is brought down, the less tension there is, and of course the less liability to this accident.

Furthermore, it is sometimes impossible in high carcinoma by any method of examination before the operation to tell the exact extension of the carcinoma to neighboring organs. My

attention was called to this in one case, a woman I operated upon two years ago in Milwaukee. I found that the carcinoma extended to the wall of the uterus from the anterior wall of the rectum, so much so that it was impossible to get all the carcinomatous tissue out, and further, it was impossible to unite the peritoneum. The patient died from acute septic peritonitis in a few days.

To what extent the difference in prognosis will be between the high and low carcinomas I do not know that it is possible to tell, because this distinction has not been made sharply enough. Thus there is nothing to judge by from the older statistics; it is only possible to guess about the high carcinomas.

It is a great gratification to modern surgery to see that such results as have been des

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cribed as following operation for high carcinoma, are possible. The mortality suggested of twenty-eight per cent. makes this operation á justifiable and a useful one.

One word as to the final results. In my limited experience there is only one case of carcinoma in which I can say that the cure is probably radical, inasmuch as more than two years have passed without a relapse. Of the rest of them, there are two who are now alive without a relapse, but they are so recent that nothing can be said about their future.

Freedom from relapse may to some extent depend upon the form of carcinoma. The more glandular or typical cylindrical celled carcinoma is more benign; the more mixed glandular or small celled carcinoma is more malignant.

The incessant complaints against the Cook County Asylum have given it a justly malodorous reputation, and as far back as 1856 Dr. Edmund Andrews of Chicago, who was Demonstrator of Anatomy at Rush Medical College, says that the corpses procured from the asylum at that time were so covered with vermin and filth as to necessitate scorching before students could dissect them. There has been repeated testimony that lice abounded in the wards, and Dr. Koller, an assistant physician, found maggots in the wounds of neglected patients in 1884. Bedbugs would torture patients under their strait-jackets and rats would mutilate the bodies of those who had died unattended during the night. Male attendants were usually appointed by the Commissioners for their fighting abilities at the polls, in fraudulently carrying elections and seemed to want to keep in practice at the expense of the insane. They often openly defied the superintendent, and when threatened with dismissal reminded that official that he had not sufficient political influence. The majority of the attendants being of this low character the efforts of those who were well disposed were discouraged.

Brawls, drunkenness, oaths, slamming of doors, incessant alarms, blackmailing, bluster, pistol shooting, intrigues, immorality, stealing, neglect of duty on part of subordinates, exerted a very depressing influence upon the decent officials there and caused them to waste much of their energies in keeping out of rows.

Dram shops were convenient to the asylum,

and poorhouse, to and from which trooped the attendants, day and night, in various stages of intoxication, and some of these places had the reputation of being "fence houses" for the disposal of stolen county property. Almost everything seemed to have"a job" in it for some one, big or little. The Commissioners claimed the lion's share of the stealages, and winked at the smaller thefts of underlings. Even the cheap keys which were purchased at dear prices would break in the locks at most inopportune times. The warden was an acknowledged stealing agent for the "gang," and among other methods of robbing not brought out on the "boodle trial” was the placing of fictitious names on the pay rolls. Many such rolls will be found signed by the same hand in receipting for employes' pay, Provisions of all kinds for the insane were below grade, and less in quantity than charged for; the milk was skimmed, and often too sour to use for long periods at a time, even when there were no thunder showers.

There were stealages in the clothing in various ways, and even the rags and bones were sold for the benefit of the one who had control of such offal.

The County Board financial reports were falsified and confused in a variety of ways, often the expression "general expenses" would cover a thousand dollars or more of unaccounted for bills, and at one time some fifty thousand dollars were included in a lump in some such item to the perfect satisfaction of the Commissioners. Whosoever arrayed himself against this state

of things was marked for persecution, and there is reason to believe that frequent political murders have taken place from such causes. A favorite method of entrapping an enemy was to fasten upon him some worked-up scheme, such as enticing him into questionable relations with females, and having witnesses in hiding.

To add to the turmoil, while the perfectly new boilers were being destroyed in the engine room to enable more stealings, and the patients were suffering for want of heat, the Commissioners would interfere with the classification of the insane by ordering violent cases, in which they happened to have an interest, to be placed upon the wards assigned to quiet and convalescing patients and otherwise interfere with the proper treatment of the insane. Everything was done to make an apparent showing of external cleanliness, but the whitewashing and the flowers and the well-kept lawn constituted it but a whited sepulcher.

Among other things which alienists abominate, but which is rife in every political asylum, is the keeping and training of "show patients," such as, by some peculiarity of manner, either clownish or otherwise, could pander to the curiosity of visitors, and particularly such insane as were adroit enough to sing the praises of the administration, through encouragement by extra favors for such services.

Advances in the care of the insane are made in direct proportion to the growth of intelligence among the people, and the publicity given to public affairs.

To properly understand the causes of public charity abuses we must not only look at immediate but remote factors. Like causes produce like effects, and we can turn to the annual reports of the Illinois State Board of Charities, wherein are detailed precisely similar, if not worse, brutalities existing in nearly every county insane asylum in the State, and then refer to the September 8th, last, accounts in the Indianapolis papers, headed "Ill treating the insane. Shocking disclosures affecting the management of the Indiana State Asylum. Ward strikers kick and whip the unfortunate inmates in a brutal manner. Putrid meat, rancid butter, and wormy flour bought and used. Democratic corruption." Some other States account for these things as Republican corruption. In our own county our "boodle gang" was chosen impartially from both parties, so we may well question whether one party is a particle better than the other, and as some of these miscreants have been known to change from one party to the other as often as five times in ten years to keep on the winning side, it shows that spoils, and

not principles, are the attractions, and at the bottom of the entire matter.

Unfortunately throughout the United States most state asylums and nearly all the county asylums are thus badly managed and for identical reasons. At Danvers, Mass., a palace asylum was built for show and spoils, while the insane were being starved in the poorhouse. At Utica, N. Y., corruption was rife and similar horrors occurred there, and we hear from New Orleans and other places in the South, especially Kentucky, of even so bad a state of things as the insane being shot at by the officials.

The State management is better than the county or municipal, because the Legislature is not so constantly in session and the medical men are more free to work reforms in the interim, and the control is placed in the hands of a board of local trustees who usually do no worse than to make the asylum and its funds the occasion of booming their particular town,

The overcrowding at our county asylum is not the only cause of the brutalities there, and the cry of overcrowding has always been made by the county commissioners as justification for more contract jobbery. The "boodlers" started that cry during 1885 and placarded the walls of the city with appeals for a million dollars with which to build a suitable asylum, and described the horrors that would occur in case of a fire at the institution.

Rather than build additions to the present miserable structure it would be better by far to abandon the county farm entire to the poorhouse management and furnish the State with funds to build elsewhere, remote from saloons and the present location, two separate asylums for males and females.

The unrestricted pauper immigration to thiscountry is a direct cause of this overcrowding. March 1, 1884, a careful enumeration showed that at the county asylum there were 464 foreign born to 146 native' born insane, in a total of 610, giving a proportion of 12 native to 88. foreign born insane, which is certainly not the percentage of our sane population, the differences between which exhibit the fact that Europe is unloading her pauper insane directly upon this country. There is a prospect of the city limits becoming coextensive with those of the county boundaries, as is the case with New York and St. Louis. In this event the County Board will cease to exist, and our charities will be dispensed by Aldermen. The change will not be for the better. Neither county commissioners nor aldermen, who are of the same stock, and elected in the same way, should be allowed to control public charities. The Tweed