Cancer, Malignant Stricture, and Malignant Ulceration

The forms of cancer met with in these regions are epitheliomatous, scirrhous, encephaloid, and colloid. Considerable diversity of opinion has existed as to which variety occurs most frequently; but it is now probably a matter of absolute knowledge that the epithelial form is the one most commonly observed, and next to that in frequency the scirrhous form. Encephaloid and colloid are of quite infrequent occurrence. Again, as to the sex in which this affection appears the most often, there is much disparity existing between surgical writers: it is usually thought to be much more prevalent among women than among men. This is not the experience of many of the authorities upon this subject, yet the statistics of the Hôtel Dieu, Paris, furnish overwhelming evidence in favor of its preponderance in women. Carcinoma of the rectum, occurring as a primary infiltration in the rectum, probably occurs oftener in men, but there are among females so many contiguous structures prone to cancerous degenerations, as the uterus, the vagina, the ovaries, the Fallopian tubes, tumors and cancerous masses occupying Douglas's cul-de-sac, that it would seem likely that they would be more frequently the victims of secondary cancerous deposit in the bowel or of erosion and extension of disease by contiguity or continuity. Epithelioma in other situations attacks men much more frequently than women. This form of disease usually occurs in middle life and in old age, but to this general rule there have been many exceptions; it has been seen in children. Allingham quotes its occurrence in a lad of seventeen, and Gowland in one of thirteen. It very rarely occurs as a secondary deposit of cancer in a remote region or organ. In the table of 4000 cases of rectal and anal disease, before referred to, cancer existed in 105. This disease is usually within easy reach of the finger, except when the growth is in the sigmoid flexure, being within an inch or two of the anus or from two and a half to three inches above it. The epithelial form, when it commences at the anus, is closely analogous to epithelioma of the lip: from the anal outlet it spreads upward into the bowel, or it may be primarily seated there. When occupying the junction of skin with mucous membrane it is sometimes sluggish, and a long time may elapse before it takes on aggressive action: induration, nodulation, obstinate fissure, or fungous growth marks its inception; as the condition proceeds, infiltration of surrounding structures takes place and large, hard, irregular masses form, which ulcerate, split, and form cauliflower excrescences. The rectum becomes blocked with fungoid growths: both these and the cancer proper are very vascular, and frequent hemorrhages occur, and an offensive muco-purulent discharge constantly oozes from the bowel.

Scirrhus of the rectum commences as an infiltration of the submucosa, which rapidly involves the other elements of the bowel, pushing hard nodules upward into the lumen of the intestinal tube: these break down and form ragged ulcers with indurated margins, and bleed profusely. Its situation is usually not higher than three inches above the anus. It has a tendency to invade all the neighboring organs and soft structures, to bind them to itself in a firm, dense mass, and to form communications with the vagina, bladder, uterus, perineum, and penis. Abscesses and fistulæ are common complications.

These neoplasms are insidious in their onset, and when seated at some little distance from the anus do not excite much pain at first. In the epithelial form the anus presents an abnormal appearance: it is inflamed and is covered with irritated, hypertrophied tags of integument bathed in a sanious, offensive fluid. Difficult defecation, of which the natural form is absent, with inordinate tenesmus, a sense of weight and fulness in the bowel, and an irritable condition of the bladder, are among the symptoms. The feces are passed in little, irregular lumps or broken fragments, or this state is accompanied by or alternates with small, liquid, offensive stools. As the diseased action proceeds, very severe local and general pain is endured: this is of a dull, lancinating character, and affects not only the diseased bowel, but involves the entire contents of the pelvis, shoots down the thighs, up the back, and into the penis: frequent and exhausting hemorrhages take place; the patient exhales a peculiar sickening odor; his complexion becomes cachectic; his strength fails; and death ensues, after a variable period of intense suffering, from a few months to two or three years after the first symptoms appeared. The modes of termination of life in these cases are—exhaustion, secondary deposition, septicæmia, peritonitis, and hemorrhage. Stricture of the bowel and very extensive ulceration attend all of these advanced cases of malignant rectal disease.

The encephaloid variety is prone to very sudden and rapid breaking down, and may destroy life within a few months. If the finger be passed into the bowel in a case of encephaloid degeneration, it will encounter a large soft tumor occluding the gut: this is a very different sensation from that imparted to the finger in a case of epithelioma or scirrhus. In the former there will be felt a crepitating, as though due to the giving way of a moist, friable substance; in the latter the touch will perceive dense, irregular nodulations and ragged ulcerations having very firm margins.

The rectum may also be involved and destroyed by any of these neoplasms in neighboring organs. A middle-aged woman who was admitted to the Pennsylvania Hospital in a very advanced stage of epithelioma of the cervix uteri died from hemorrhage from the rectum and uterus in eight minutes. At the autopsy it was found that the disease had almost separated the cervix from the body of the uterus, had involved the cul-de-sac of Douglas, and had eroded a large opening into the rectum. Numerous ends of large vessels were observed which had undergone erosion.

Carcinoma of distant organs does not seem to frequently involve the rectum by secondary deposition. "In 160 cases of gastric cancer examined at the Pathological Institution in Prague, Dittrich found secondary cancer of the rectum only twice."

Leube, Ziemssen's Cyclopæd., vol. vii. p. 235.

In these cases of carcinomatous disease originating in the bowel the neighboring lymphatic glands are indurated and enlarged, and secondary deposition in neighboring and distant organs is the rule.

The lower portion of the intestinal tract may become involved in disease by direct extension from the colon, as in dysentery following enteritis or entero-colitis. Habersham says that diarrhoea arises generally from an irritated condition of the large intestine, catarrhal and mucous diarrhoea from slight inflammatory disease closely allied to ordinary coryza affecting the mucous membrane of the large intestine. "In the diarrhoea of soldiers the lesions of the large intestine have been either those of congestion with varying degree of extravasation or of ulceration more or less extensive. The colon in the former cases has invariably presented patches of intense congestion, and in numerous instances extravasation, the amount and intensity varying in different subjects, in a few the whole mucous surface of the intestine having a livid red color; in others tracts of more or less intense congestion at irregular intervals, as in the small intestines, would be noticed. The ileo-cæcal valve almost invariably presented intense congestion. The rectum has uniformly presented intense congestion, with more or less fibrinous exudation. Frequently the presence of fibrinous exudation was a question of doubt." The entero-colitis or ordinary summer complaint of infants not infrequently causes a very troublesome form of proctitis. Besides the ordinary causes of dysentery, Feyrer states that it is caused by irritation of the solar plexus of nerves, also by the inhalation of sewer emanations and by the ingestion of impure water.

Med. and Surg. History of the War of the Rebellion, vol. ii. p. 102.

Times and Gazette, 1881, p. 87.

"In dysentery the anus becomes bluish-red, and is even marked with cracks and rents; it is painful to the touch and tightly contracted. In the later stages of severe cases it becomes large and gaping; then the stools are generally discharged unconsciously, and the pain is slight, paralysis of the sphincter ani having occurred. These symptoms indicate generally that death is to be expected. In some of these cases the pathological lesions are limited to the rectum. Dysentery may succeed typhoid fever."

Heubner, Ziemssen, vol. i. p. 552.

"Pigmentation is common after dysentery, and also after typhoid fever when dysentery has existed. Pigment-deposits are encountered in the large intestine in those who have suffered from repeated attacks of acute diarrhoea or from protracted flux. They may be seated as diffuse patches on the general surface of the mucous membrane or may be more especially localized in the closed glands. The diffuse form of these deposits is more frequently encountered in the large than in the small intestine, and is apt to be more intense in the former, producing darker and more extensive discoloration; hence the ash- and slate-colored, greenish, and blackish tracts which are so frequently observed in the cæcum, colon, and rectum." Follicular ulceration of the rectum sometimes follows chronic dysentery and typhoid fever. Woodward has observed that a catarrhal condition of the rectum commonly occurs in typhoid fever cases. Referring to typhoid fever lesions of the large intestine, Rokitansky says: "The ulcerative process is by no means confined to the small intestine; we have seen the mucous membrane of the large intestine riddled with ulcers. They were many of them of large size, and had clean-cut, non-thickened margins. This condition, indicating the absence of reparative action, is not nearly so frequent as that of thickening and induration, which generally took place to some extent in the edges of the ulcers. The bottoms of the ulcers are commonly formed by the submucous tissue. Sometimes the muscular fibres are completely exposed: this, however, is generally the result of secondary advance subsequent to the reception of the morbid action."

Med. and Surg. History of War of Rebellion, vol. ii. p. 308.

Jones and Sieveking, p. 590.

John Harley calls attention to the intestinal lesions of scarlatina as follows: "I know of no disease in which the morbid effects are more uniform. Scarlatina is essentially a disease of the lymphatic system. It is attended with inflammatory action of this system of glands, in which are included the agminated glands of the intestine. In 28 cases examined, 8 had the solitary glands of the large intestine enlarged and inflamed; in 1 there was acute desquamation of the mucous membrane of nearly the whole of the large intestine. In about half the cases the large intestine was found healthy."

Med.-Chir. Trans., vol. iv. p. 102.

The rectum and anus are frequently subject to attacks, by contiguity, from diseases in neighboring organs. The most frequent of these is doubtless that form of ischio-rectal abscess which invades the bowel, causing fistula in ano. Various neoplasms having their seat in the tissues or organs near the bowel may obstruct it by simple mechanical pressure, or may cause inflammation, infiltration, and ulcerative erosion. Mechanical encroachment by the pressure of a foreign body in the vagina may cause grave interference with the normal functions of the lower bowel. At the out-patient department of the Pennsylvania Hospital in 1880, Arthur V. Meigs, assisted by Wetherill, removed a large, hollow, glass ball-pessary from the upper end of the vagina of an aged woman, who declared the pessary had been so placed by a physician sixteen years before, and had remained ever since, despite her repeated efforts to remove it with an ordinary table-fork. Upon its extraction, which was accomplished with difficulty, a small portion of its surface was found covered with scratches. Its presence had caused constipation, impaction of feces, and atony of the rectum.

Interference with the rectal functions often follows tedious cases of labor where the child's head remains long in the perineum.