bowels will give no sign of its presence; indeed, cases have been
observed where, death having occurred from other causes, the existence
of the malady became apparent only at the necropsy. In all cases the
symptoms are, at first, of an indefinite character and very inconstant.
Vague abdominal pains are experienced; these gradually tend to become
referable to a certain locality and to become associated with irregular
action of the bowels. Constipation, alternating with short intervals of
diarrhoea, supervenes, and a varying amount of meteorism is developed.
These symptoms may be attended by the signs of failing nutrition. The
body gradually shows the effects of chronic imperfect assimilation, and
becomes emaciated. The complexion slowly assumes the peculiar hue of
chloasma cachecticorum. Long before this occurs, however, the cancerous
new formation usually becomes perceptible as a more or less distinct
abdominal tumor, movable or fixed, as the part affected permits of free
movement {870} or is bound down to the neighboring parts either by
normal attachments or by adhesions resulting from inflammatory
processes or from the extension of the cancerous growth. When the tumor
is movable, it is generally situated in the small intestine or
transverse colon or sigmoid flexure, the other portions of the
intestinal canal being comparatively fixed. It should be mentioned,
however, that portions of the intestines normally freely movable may
become adherent to contiguous parts, as the transverse colon, with the
gall-bladder, liver, stomach, spleen, etc. etc.; the transverse colon
and small intestine, drawn down by the weight of the new growth, with
the pelvic organs, the bladder, uterus, uterine appendages, etc.; and
that, finally, different portions of the bowels may become involved in
one mass.
When the duodenum is the portion implicated the tumor may escape
observation or may be indistinguishable from cancer of the pylorus. It
occasionally happens that no tumor can be discovered until the malady
is far advanced whatever part of the bowel is affected. In nearly all
cases, however, before very long the tumor will be detected wherever
situated, but it will often remain difficult, owing to its situation,
to arrive at exact conclusions as to its precise character. Usually, it
offers considerable resistance to the touch, but its features may
readily be obscured by the fecal accumulation that forms above the
constricted portion of the gut and by the gaseous distension of the
bowel. This tumor will be slightly painful to pressure, and the patient
will refer to it a spontaneous pain, usually of a dull aching,
sometimes of a stabbing, character. Percussion yields a sound of
muffled resonance, due to the tubular nature of the tumor. Cancerous
neoplasms of the bowel, and of the duodenum especially, are apt to be
associated with a distinct pulsation caused by the subjacent abdominal
aorta. This may readily be distinguished from aneurismal pulsation by
the absence of an expansile character, by the disappearance of the
impulse that may sometimes be observed when the patient is made to
kneel upon all fours, and by the occasional mobility of the cancerous
tumor. By extension and by inflammatory infiltration the tumor
frequently becomes converted into a conglomerate mass where all
determination of locality becomes conjectural. The tumor is, with very
rare exceptions, single.
The symptoms that accompany the development of these growths depend
mostly upon their position in the alimentary tract. Pain alone seems
independent of this, but is at best a most uncertain concomitant. When
the duodenum is the part affected by extension from the pylorus, the
symptoms are indistinguishable from ordinary pyloric cancer. Even
primary cancer of this part may exactly simulate pyloric cancer. The
localized pain and tumor, the vomiting after meals, the frequent
presence of blood in the vomited matters, the progressive emaciation
from starvation, the absence of abdominal distension (a result of the
constriction of the gut at its upper extremity), the gastric
dilatation,--all combine to make the diagnosis difficult.
Cancer of the duodenum in its descending part may be suspected when
signs of hepatic and pancreatic obstructive difficulties point to
implication of the ducts, through which are produced jaundice upon the
one hand, and evidences of imperfect pancreatic digestion, in the
presence of undigested fat in the stools, upon the other. In the lower
portions of the {871} intestines the cancer becomes more and more
associated with meteorism and fecal accumulations. Constipation becomes
steadily more obstinate, but there are occasional fluid evacuations
containing blood, pus, and mucus, often stinking abominably. When the
tumor is toward the end of the large intestine--in the sigmoid flexure,
for example--fluid discharges occur with very great frequency at times;
but these are scanty in amount and but slightly fecal in character. In
these cases one does not usually observe the compressed, ribbon-like
stools that are seen in rectal cancer. These symptoms may precede the
appearance of the tumor, when the diagnosis will be less readily made.
The constipation will at first be more amenable to the use of
purgatives. (It is said to be due more to a loss of contractility of
the bowel than to the narrowing of its lumen.) Gradually these will
lose their efficacy, and finally complete obstruction of the lumen of
the gut is effected; in which event the symptoms of ileus will develop,
with cramps and vomiting, finally of a fecal character, and the fatal
issue quickly follow. Not unfrequently peritonitis is developed, and
may be of a chronic character or may destroy life within a day or two,
or the patient may die from exhaustion before the obstruction becomes
complete.
It may happen that the integument will become involved in the malignant
process, or may become continuous with the tumor by adhesive
inflammation. In such cases an opening may be formed by suppuration, or
the lancet may secure the passage of feces through an artificial anus,
and temporary respite be obtained. Sometimes a sudden disappearance of
the symptoms of obstruction--a result due to the softening and breaking
down of the cancerous mass, restoring temporarily the integrity of the
intestinal tube--may give an unjustifiable hope to the patient; or the
same effect may follow the establishment of a communication, by
ulceration, between the bowel above the tumor and some portion nearer
to the anal orifice. The progress of the new growth soon annuls the
benefits thus gained.
Not uncommonly, particles of the cancerous mass may become detached,
and, if diligently searched for, may be discovered in the feces.
Microscopic examination may then definitely determine the nature of the
disease. It has been claimed that colloid cancer may be diagnosticated
in this manner even before the appearance of other symptoms.[5] Death
may be hastened by the occurrence of metastatic deposits in other and
vital organs. Oedema of the lower extremities (of the left extremity in
cancer of the sigmoid flexure) will often be observed as a result of
the interference of the cancerous mass with the return of blood from
the extremities by pressure upon the large veins. The combination of
pain, tumor, constipation, tympanitis, progressive wasting, and the
cachexia that sooner or later supervenes, stamps eventually most cases
with unmistakable characters.
[Footnote 5: Charon and Ledegank, _Journ. de Med.-Chir. et de Pharm._,
v. lxviii., 1879, p. 493.]
The duration of intestinal cancer may extend from several months to
one, rarely two, years, the latter age sometimes being attained by
colloid cancer, the most chronic and least malignant form.
MORBID ANATOMY.--By far the most frequently encountered malignant new
growth of the bowel is carcinoma, in one or another of its forms. The
cylinder-cell epithelioma is probably the most common of {872} these,
and, as seen in the intestine, offers many naked-eye points of
resemblance with ordinary encephaloid carcinoma. It is soft, filled
with a milky juice, and may attain considerable size. The tumors appear
as discoid prominences of varying size and number. Later, these may
become fungoid and ulceration ensue. The growths early involve the
whole intestinal wall, and by their increase tend to obstruct the
passage of the intestinal contents. When ulcerated they present a
nodular, uneven surface, situated upon a thickened base consisting of
the infiltrated coats of the bowel. Villous prolongations (villous
cancer; the undestroyed connective-tissue stroma) may project into the
lumen of the bowel and give a peculiar tufted appearance to the part
implicated. One or more points may be invaded by cancerous growth, and
above each will be developed a dilatation of the gut (the result of
distension) containing uncertain quantities of fecal matter, upon the
removal of which the tumor will appear much smaller than it appeared
during life.
Scirrhus usually implicates the gut in its entire circumference, so
that a high degree of constriction may result from a small amount of
cancerous infiltration. It begins as small nodules or plates upon the
mucous membrane. As commonly observed, the lumen of the intestine is
narrowed by an annular band of gristly hardness. All the coats of the
bowel, with the peritoneum, become involved, and frequently the
contiguous parts are included in the cancerous infiltration, forming an
undefinable mass through which the contracted channel of the bowel may
be traced, though often impervious to any but the smallest articles (a
crow-quill, for example). The surface of the gut is generally
ulcerated, irregular, and nodular. The walls of the ulcer are irregular
and infiltrated. It will sometimes happen that the autopsy reveals
permeability of the bowel where total obstruction prevailed during the
latter days of life. This may be probably accounted for by the
disappearance of the hyperæmia that doubtless existed during life and
caused more or less turgidness of the growth. Sometimes the
connective-tissue element is less predominant, and gives place to a
more or less luxuriant cell-development; in a word, scirrhous carcinoma
is replaced by soft or encephaloid cancer. This difference is simply
one of degree, but is associated with greater rapidity and extent of
growth. Ulceration is extensive, and one may here also often discover
the villous, tufted appearance of villous cancer, caused by the
fringe-like shreds of stroma entangling cellular elements not yet
detached from the mass.
Colloid cancer, or carcinoma gelatinosum, may be associated with either
of the above-described forms as a degenerative form, or may,
apparently, develop as such from the beginning. It is a very frequent
variety of the malady. In 27 cases of intestinal cancer, colloid cancer
was present in 5, as reported by Lebert. It is most often observed in
the sigmoid flexure and cæcum, as are the other forms of carcinoma. It
is composed of a considerable mass extending around the bowel.
Ulceration is less often found here than in the other forms, nor is
there the same tendency to secondary infiltrations. By the unaided eye
an alveolar structure may be detected, and when the mass is extensive a
soft, jelly-like consistency is presented, together with "a bright,
honey-yellow color." Small deposits of the colloid matter may be seen
upon the surface. These have been described as resembling wheals of
urticaria or herpetic or eczematous {873} vesicles (Bristowe). The
glairy fluid of colloid carcinoma oozes from the cut surface of the
tumor, bathes it, and is to be found in the intestine.
These different forms of cancer sooner or later invade neighboring
parts, as the peritoneum, mesenteric and retro-peritoneal glands, and
adjacent organs. On the other hand, the intestines may become invaded
by cancer of the peritoneum and other parts. It has even been observed,
reversing the usual order of things, as secondary to cancer of the
liver (Wilks and Moxon). Under these conditions the symptoms of
intestinal cancer will have been associated with those due to the
primary affection. Lympho-sarcoma will rarely be found as an extension
from the lymphatic glands and involving the small intestine. Melanotic
sarcoma may occur as metastatic from an original melano-sarcomatous
tumor of the skin or eyeball.
DIAGNOSIS.--In its earlier stages it is impossible to recognize cancer
of the intestines. After its symptoms have become established they may
resemble those of several disorders. Cancer of the duodenum cannot be
distinguished from that of the pylorus unless evidences of pancreatic
or biliary disturbances indicate obstruction to the passage of the bile
and pancreatic secretions. Previous to the appearance of a tumor one
must often remain in doubt. The alternations of constipation and
diarrhoea, the signs of partial obstruction, the localized pain usually
present, the gradual wasting, will arouse suspicions of cancer, though
chronic inflammatory affections of the bowels may induce symptoms not
altogether unlike these. The presence of a tumor will supply the
additional evidence necessary for a definite diagnosis. It will be
necessary to exclude fecal enlargements of the bowels. The cancerous
tumor will be somewhat painful, hard, nodulated. A tumor due to fecal
accumulation may closely simulate it, and is, indeed, usually
associated with it. By manipulation the fecal mass may be moulded, and
even displaced, and by appropriate purgative treatment may be caused to
entirely disappear. Foreign bodies, mesenteric tumors, and other
abdominal enlargements may offer physical resemblances to intestinal
cancer, but their symptomatology is usually so different that doubt may
be easily dispelled. Syphilitic gummy infiltration, with resulting
stricture, is more apt to occur in the rectum than in other parts of
the alimentary tract.
The presence of fragments of the new growths may sometimes be detected
in the stools, when microscopic examination will determine their
nature. With cylinder-cell epithelioma and glandular cancer this is not
common, but with colloid cancer much information may be gained by
examining the evacuations. According to Charon and Ledegank,[6] colloid
cancer of the intestine may be detected before symptoms develop, by the
presence of colloid matter in the feces. In the later stages, however,
the gelatinous change of all the histological elements may occasion
embarrassment, as at this stage the peculiarities of the cellular
structure will have been destroyed.
[Footnote 6: _Journ. de Med.-Chir. et de Pharm._, lxviii., 1879.]
PROGNOSIS.--Intestinal cancer always proves fatal. Death may result
from the debility resulting from the cancerous cachexia or from
intestinal occlusion or from peritonitis. The duration of the malady is
usually not long. It runs its course in from several months to one,
rarely to two, years.
{874} TREATMENT.--Treatment must be directed to the alleviation of the
distress caused by the disease. No curative treatment is known. When
the cancer is situated in the colon, especially in the sigmoid flexure,
the operation for artificial anus often affords great though temporary
relief. The diet should consist of such articles in the digestion of
which a large residue is not formed. Milk, eggs, soups, etc. should
compose the principal articles of food. Mild laxatives will be required
to secure the proper evacuation of the bowels, and to relieve pain and
discomfort opium is invaluable and should be freely used. When
obstruction is imminent nutrient enemata afford the most efficient
means of administering nourishment.
Lardaceous Degeneration of the Intestines.
SYNONYMS.--Albuminoid degeneration, Waxy degeneration, Amyloid
degeneration, etc.
Lardaceous degeneration of the intestines is an affection of quite
frequent occurrence in those persons who are the subjects of a like
change elsewhere; for although it has been asserted that it may be
present as a primary affection, it almost always succeeds the same form
of degeneration in other organs. Since, for the most part, it only
makes itself manifest at an advanced stage of the disease, its
importance is usually masked by the grave constitutional condition of
the patient, whose vital forces are wellnigh exhausted by the already
advanced degenerations present elsewhere. The extensive implication of
other organs and tissues in the same degenerative process also creates
great obscurity in the symptomatology of intestinal lardaceous disease,
and is doubtless the cause of the existing dearth of definite knowledge
upon the subject.
That the intestines are comparatively frequently involved in lardaceous
disease is shown by dead-house statistics. Thus, Charlewood Turner[7]
reported from the London Hospital that in 58 cases of lardaceous
disease the intestines were affected 10 times; and Goodhart[8] in 150
consecutive necropsies of lardaceous disease at Guy's Hospital reported
implication of the intestines 63 times.
[Footnote 7: _Transactions Path. Soc. London_, 1879, p. 517.]
[Footnote 8: _Ibid._, p. 533.]
Although the bowels do not become affected as early as several other
parts, they will almost certainly become involved should the patient's
life be prolonged; and in those cases where death is a direct result of
the degeneration the intestines share with the kidneys the chief
responsibility. It is not, however, until an advanced stage of
lardaceous degeneration that its presence in the alimentary canal is
revealed by symptoms; indeed, many cases do not, throughout life,
betray evidences of the pronounced alterations that are to be
discovered after death. Even in extreme cases there are no symptoms
that would, even with probability, be referred to lardaceous disease of
the bowels in the absence of the same degeneration in other organs and
parts. There are, then, no specific symptoms following lardaceous
degeneration of the bowels.
Where the normal functions of the intestines can no longer be properly
performed in consequences of the changes that have taken place in them,
there results a moderate diarrhoea. At first the number of movements
{875} may not be increased; the evacuated matters are fluid and of a
greenish or pale color. Usually, little or no pain is experienced,
though at times and in certain individuals this may be severe and
colicky. The diarrhoea is not always steadily progressive, but may from
time to time disappear. With the progress of the disease it may become
more free and persistent, and in the later stages hemorrhage from the
bowels may be superadded. This may vary in amount, and where, as is
often the case, the stomach participates in the degeneration,
hæmatemesis may also appear. These hemorrhages may be insignificant, or
may at once assume alarming proportions, and even bring to an
unexpected termination the life of the individual. Already, at the
outset of the intestinal symptoms, the general health will have shown
evidences of profound alteration, but upon the supervention of the
diarrhoea more rapid progress will be observed, consequent upon the
increased nutritive disturbance. The use of remedies in temporarily
controlling this diarrhoea may prolong for months the life they are
powerless to save.
So far as concerns the intestinal affection, there is no special
tendency toward febrile excitement. It must not be forgotten, however,
that acute inflammatory attacks of various tissues and organs
frequently arise in the course of lardaceous disease.
Though there seems to be reason to believe that mild degrees of
lardaceous degeneration may sometimes be cured, especially when
dependent on syphilis, there is but little hope of arresting its
progress at the late stage when the bowels become implicated. Indeed,
when pronounced degeneration of the bowels takes place the disease is
usually nearing the end of its course; for it is a well-settled fact
that in this degeneration extensive implications of organs may occur
without markedly reducing the patient's general condition, so long as
the kidneys and intestines remain unaffected. The cause of death is
usually to be traced to these organs. Dickinson[9] found that in 35
cases where death was apparently due to renal lardaceous disorder, the
immediate result was brought about by diarrhoea in 13 cases.
Presumably, in a large proportion of these lardaceous disease of the
bowel was present.
[Footnote 9: _Diseases of Kidney_, Part ii., 1877, p. 496.]
The degeneration usually affects the lower portion of the small and the
upper part of the large intestine. Occasionally it will be found to
have invaded the whole alimentary tract. As in lardaceous degeneration
generally, the process begins in the small arteries and capillaries and
veins, affecting primarily the arterial and venous muscular coats--not,
however, according to the latest authorities, the muscular fibres
themselves, but their perimysium and the cement substance, the
degeneration being one limited to the connective tissues.[10] In the
mildest cases only some of the small vessels of the mucous membrane are
involved, and no naked-eye changes can be detected. In more advanced
stages the mucous membrane is pale and shows evidence of catarrh.
Thickening occurs, and as the process advances a peculiar appearance is
revealed which has been compared to that of wet wash-leather (Wilks).
The iodine test now gives the mahogany-colored reaction of lardaceous
matter, with the tissues affected, or, if the methyl-aniline-violet
test of Cornil be employed, the lardaceous material will display a
red-violet color, while {876} normal structures will be tinged
blue-violet. It is said to be better to make the test near a Peyer's
patch, since the latter is seldom affected by the degeneration, and
brings out, by contrast, the surrounding lardaceous material.[11] This
distribution of the material cannot be considered as constant, however,
since Hayem found the patches of Peyer most frequently affected.
[Footnote 10: Cohnheim, _Allgem. Path._, 1882, p. 667.]
[Footnote 11: Wilks and Moxon, _Path. Anat._, p. 404; Kyber, _Virchow's
Archiv_, Bd. 81, H. 1 and 2.]
In more advanced stages the surface may become irregular from glandular
enlargement, and ulceration may occur. Microscopic examination shows
the lardaceous material in the vessels, and also in the stroma of the
mucous membrane and villi.[12] The epithelium is not involved. The
degeneration, at first confined to the mucous membrane, extends to the
submucous tissue, the proper muscular coat of the intestines being
often implicated--so far, at least, as concerns its connective tissue.
In the more severe cases Hayem found the agminated and solitary glands
extensively involved. Fine branches from affected vessels penetrate to
the interior of the glands. In such cases the mesenteric glands will be
found implicated. The degeneration of the vessels running through the
gland structure causes disappearance of this substance by fatty
degeneration, and occasions a reticulated arrangement of the lardaceous
material, and, secondarily, ulceration. In a similar manner ulcers may
arise in any part of the affected tract. Finally, the lardaceous
material may involve the whole thickness of the gut.
[Footnote 12: Eberth, _Virchow's Archiv_, 80, S. 138.]
The diagnosis of lardaceous disease of the bowels can only be made with
certainty in the presence of pronounced albuminoid disease of other
parts in association with the symptoms of intestinal disorder. It
possesses no characteristic symptoms.
Inasmuch as the disorder invades the bowels only at a late stage of its
existence, the prognosis acquires additional gravity. It is probable
that advanced albuminoid disease is never cured; so much the more
hopeless is it when affecting this tract. If unchecked, the diarrhoea
rapidly saps the powers of life; if temporarily alleviated, the
approach of death is more gradual.
Whatever attempts are to be made to cure the disease, they must be
through the general system, and are identical with those directed
toward the cure of lardaceous disease generally. Treatment directed to
the intestines must be palliative. The diarrhoea must be combated by
appropriate diet and the administration of such remedies as protect the
surface of the mucous membrane and control the intestinal movement.
Bismuth subnitrate in large doses is therefore indicated. Various
astringents may be employed, while the use of opium often secures most
gratifying relief. It should be given in generous doses. Preparations
of the crude drug seem to answer better than its salts. The necessity
of keeping the gut free from undigestible matters that may irritate the
already badly-damaged mucous membrane is apparent. Patients with this
form of lardaceous degeneration usually show the cachexia resulting
from profound modifications of nutrition, and their intestinal symptoms
can only be regarded as links in a long pathological chain. Hemorrhage
will call for remedies that under ordinary circumstances are employed
to control bleeding from the bowels.
{877}
DISEASES OF THE RECTUM AND ANUS.
BY THOMAS G. MORTON, M.D., AND HENRY M. WETHERILL, M.D., PH.G.