CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 13)

masses, which extended deeply down into the right iliac fossa. The patient had no conception of any trouble beyond constipation and " rheumatism," though the whole lower extremity on the right side was oedematous. By careful diet and laxatives the threatened obstruction was avoided, and the man gradually sank with all the signs of the cancer- ous cachexia, and died three months from the first examination. Unfor- tunately no autopsy could be obtained. From what has been said, it is evident that there is little in the his- tory which the patient will give of cancer of the rectum to distinguish it from ulceration and stricture of any other variety, and that the diagnosis must chiefly rest upon a physical examination. To make such an exami- nation thoroughly, and yet safely, requires great care and gentleness, and, to properly interpret the conditions which may be found, no little experi- ence and knowledge. It requires many years of practice to reach the point AUingham has reached when he says: '^ There is something peculiar about the feel of cancer which the practised finger rarely mistakes even for simple indurated ulceration. I think it is many years now since I mis- took the one for the other." In the majority of cases the diagnosis may be made by the history and by physical examination with the finger alone. Cancer in this locality is a disease of rapid growth, and when a patient says that stricture has existed any considerable number 6t years the idea of malignancy may be abandoned. Something also may be learned from the general appearance of the patient, but most of all from the digital examination. When the » Op. cit., p. 566. CANCEB. 231 disease is seen in its earlier stages^ the hard^ more or less distinctly circnm- scribed new growth which has infiltrated the wall of the bowel is diagnos- tic. The great difficulty is to distinguish between an advanced case where the rectum is partially occluded by hard masses of disease, and an old case of stricture and ulceration which is not malignant. This may sometimes be impossible except by the microscope, and syphilitic disease of the rectum is not infrequently mistaken for cancer. When a soft friable mass of epithelioma is found seated on a hard, infiltrated base, which is ulcerated in spots, the edges of the ulcers being hard and raised, the diagnosis is also easy. Cancerous stricture of the sigmoid flexure will show itself sooner or later either by examination through the abdominal wall, or by the signs of intestinal obstrut^tion. In cases where the condition is more complicated and where secondary deposits — in the liver, for example — have begun to do their fatal work before actual obstruction has begun, these symptoms of stricture may all be obscured by the presence of others which shall more readily attract the eye. In a case which I now have under treatment, I had made the diag- nosis of cancer of the liver with ascites and great intestinal disturbance some time before my attention was called to the rectum, and it become evident by examination that the affection of the liver was secondary to malignant disease high up in the rectum, which was also gradually involv- ing the pelvic viscera. The greatest caution shoiyld be exercised in the examination for cancerous disease above the lower four inches of the rectum. Treatment. — The treatment of malignant disease of the rectum is de- signed to be either curative or palliative. In a small number of selected cases a cure is, perhaps, possible, as with cancer of feeble malignancy in other parts of the body — e. g,j epithelioma of the lip. At all events, the disease may be removed, and its return delayed for many years. This fact, we believe, may be accepted as proved by a sufficient number of carefully examined cases, from which the chances of error in diagnosis and subsequent history have been eliminated. Cure can, however, only be effected by excision. All other means may be set aside as hopeless failures. The operation of excision, which, after being fully described and ably advocated by Lisfranc in 1830, was allowed to fall into disuse, has again, within the past few years, become popular. It would probably be a waste of time to inquire to whom the credit of reviving it is due. Cases of its occasional performance are scattered through the surgical literature of the rectum from the early part of the cenfcury to the present, and just now it is at the height of its popularity. Like every other surgical procedure at that point of its history, it is perhaps also occasionally done when it were better to be content with less radical measures. As a result of a careful search among the statistics of this operation, Oripps ' gives the following ^ Op. cit., p. 1C6. 232 DISEASES OF THE BECTUM AND ANUS. figures. Out of a total of sixty-four cases, eleven died as a direct result of the operation; six from peritonitis, one from cellulitis, and four from accidents incident upon any surgical interference. In the fifty-three cases of recovery, the subsequent history is unknown in sixteen, and in three more the diagnosis was so doubtful as to exclude them from the list. No case is worth much in the consideration of a question such as this where the diagnosis has not been verified by the microscope in competent hands; for there are non-malignant growths of this part which, to the naked feye, strongly resemble cancer. We have then a remainder of thirty-four, in whom the disease returned in twenty; but of these twenty, several were operated on a second time for a re- currence of the growth, or possibly for a small nodule which had not been removed at the first operation, and after this secondtoperation remained free. This leaves, however, a total of twenty-three out of sixty-four ope- rations in which the disease had not returned after an interval varying from a few months to over four years — a, limit reached in three cases. This is certainly an encouraging result for this disease, and the fact that undoubted cancer may be removed and not reappear for such a length of time is decisive. Some operators, however, report better re- sults than these, and some have not been so successful. Curling ' gives one case of removal of an epithelioma in which there had been no return in the rectum after seven years, though for one year there had been " a doubtful tumor of the pelvis.'* Velpeau and Verneuil each report cases in which the cure has seemed permanent, and Chassaignac gives several in which there hod been no return after six years. Dieffenbach's thirty cases in which the patients lived many years without a return are gener- ally looked upon with suspicion. AUingham," on the contrary, considers the partial removal of the circumference of the bowel as unsatisfactory. In all of his thirteen cases in which he was able to follow the progress of the case for one year, there was either a return of the growth in the rec- tum or the glands in the groin became affected, and there ensued disease in the internal organs. In four cases the disease did not return in the bowel, but in the inguinal glands, proving that it was not due to an in- complete operation. With regard also to his ten cases of total extirpa- tion, he speaks very cautiously. He believes that a cure is very uncom- mon, and not generally to be expected; and he does not commit himself even on the question of the prolongation of life. The mortality, as a direct result of the operation, is generally about twenty-five per cent.' BiHroth * reports thirty-three cases. Thirteen died of the operation, and the remainder all died within two years, most of them of recurrence. ^ Diseases of the Rectum, ed. of 1876, p. 164. ' Loc. cit., p. 277. < Molliere, Traite des Maladies du Rectum et de TAnus, Paris, 1877, p. 627. * Clinical Surgery. Extracts from the Reports of Surgical Practice Betweea the Years 1860-1876. By Th. Billroth. New Sydenham Society, 1881. CANCER. 233 The deaths immediately following the operation were invariably due to retro-peritoneal suppuration, characterized by acutely septic symp- toms. Most of them died within from four to eight days. Since then, in certain cases, we are justified in expecting recovery from the operation itself, and such a length of life as would not result were the disease left to its natural course, we may ask : 1. What are the dangers, and what is the mortality of the operation? 2. In what class of cases is it applicable? 3. What are its results as a curative and as a pal- liative measure, and how do these results compare with those of lumbar colotomy? 4. What are the results as regards the subsequent condition of the bowel, and the control of the fascal evacuations? 5. What is the best method of its performance? For the purpose et arriving at a knowledge of what experience has already taught in this matter, I collected, a couple of years ago,^ the re- > For the full literature of the cases upon which these conclusions are based, the reader is referred to the following bibliography: Agnew. — Phil. Med. Times, June 23d,^877. Allingham. — Diseases of the Rectum, 8d ed., London, 1879. Briddon. — ^Med. Record, January 6th, 1877. Bushe. — ^Treatise on Diseases of the^Rectum, New York, 1837, p. 294. Byrne. — ^Annals of the Anat. and Surg. Soc., May, 1880. Baumes. — Bull, de FAcad. Roy. de M6d., t. x., p. 936. Chassaignac. — ^Traite de T^crasement lineaire, Paris, 1856. Cripps. — Cancer of the Rectum. Crosse (quoted by Mayo). — Observations on Diseases and Injuries of the Rec. tum, London, 1838, p. 210. Curling. — Observations on Diseases of the Rectum, London, 1851. Med. Times and Gaz,, March 14th, 1857. Dennonvilliers. — Gaz. des Hop., 1844. Desgranges (quoted by MoUi^re). — ^Maladies du Rectum, etc., Paris, 1877, p. 627. Dieffenbach. — Die operative Chirurgie, Leipzig, 1845. Dolbeau. — ^Th^se de Fumouze. Duplay.— Gaz. M6d. de Paris, 1872, p. 486. Dupuy. — Bull, de la Soc. Anat., Paris, 1872. 2"' s., xvii., p. 242. Emmet. — ^Principles and Practice of Gynaecology, 1st ed., Philadelphia, 1879, p. 511. Ewart. — ^Lancet, June 21st, 1879. Fenwick. — Montreal Gen. Hosp. Reports, vol. i. Gay.— Lancet, June 28th, 1879. Gosselin.— Gaz. des Hop., 1879, p. 921. Hohner.— Hospitals-Tidende, March Slst, April 7th, 14th, 1880. Holmes.— Trans, of the Clin. Soc. of London, 1878, p. 118. Holt (quoted by Curling), op, cit Keyes. — ^Arch. of Med., August, 1879. King.— Brit. Med. Jour., June 2l8t, 1879. Kumar.— Wiener med. Woch., 1878, p. 1,070. Labb6.— Gaz. des H6p., June 4th, 18th, 1880. Levis.— Arch, of Clin. Surg., February, 1877. 234 DI8BA:8BS OF THB BEOTITIC AND ANUS. « ports of operations up to that time as far as they were then attainable. The list at that time included one hundred and forty cases. At that time I arrived at the following general conclusions concerning the opera- tion, and subsequent study of the question has led me in no way to alter them. 1. AUhotcgh there fiave been a few cases of excision in which the cancer has not returned in a number of years, such a result is so rare as not to justify the exposure of the patient to the risk of immediate death which attends the attempt to remove extensive disease. Regarding the question of radical cure, we find difficulty in establish- ing exact dates, and have to take into consideration the reputation of the reporter. We find, howeyer, that in one hundred cases (deducting those immediately fatal, and seventeen which passed out of observation imme- diately after operation) we have five cases of reported permanent cure, in which there had been no return for at least ten years. Three of these are reported by Volkmann, and two by Velpeau. March, of Albany, has been credited with another case of radical cure, but the author is much indebted to the present Dr. Marcher a letter stating that the case of Lisfranc— Th^se de Pinault, 1829. Maisonneuve.— Union M6d , 1865. Also Th^se de Cortes, 1860. Mandt— Revue M6d., 1836, p. 264. March. — ^Trans. of the N. Y. State Med. See., 1868; also Med. and Surg. Re- porter, June 0th, 1877. Mayo. — Observations on Diseases and Injuries of the Rectum, London, 1833, p. 212. Moore. — Med. Times and Gaz., March, 1857. Molli^re. — ^Th^se de Carcopino, 1879. Nussbaum. — ^Aerztlich. Intelligenzblatt, 1868. O'Hara. — Phila. Med. Times, vol. viii. Paget (quoted by Cripps), op. cit Peters. — Arch of Med., August, 1879. Pital du Gateau.— KExperience, t. vL, p. 27. Polaillon.— Gaz. desH6p., 1879. Post.— Med. Record, July 81st, 1880. R^camier.— These de Masse, 1842. Roddick. — ^Montreal Gren. Hosp. Reports, vol. i. Schuh. — ^Abhandlung der Chir. und Operationslehre, Wien, 1867. Siebold (quoted by Curling), op, cit, Simon.— Lancet, 1851, ii., 1882. Simon, of Rostock. — ^Deutsche Klinik, 1866. Stimson. — Arch, of Med., August, 1879. Terrillon. — ^Th^se de Carcopino, 1879. Van Buren.— Arch, of Med., August, 1879. Van Derveer.— Med. Record, September 20th, 1879. Velpeau. — ^Nouveauz Siemens de Med. Operatoire, Paris, 1839, voL iv., p. 814. Vemeuil (quoted by Marchand). — ^Etude sur TExtirpation de I'Extr^mite In- f^rieure du Rectum. Volkmann.— Klin. Vortr&ge, March 13th, 1880. CANCER. 235 supposed radical cure reported by his father passed out of obsenration at the end of one year. There are some other cases which have been in- cluded in the category of permanent cures— cases in which the disease had not returned in four or five years — ^but the great majority recur within the first year and are fatal within two. 2. The operation is chiefly valuable as a palliative measure and as such it compares favorably with colotomy both in prolonging life and relieving pain. The treatment of cancer of the rectum by excision has not yet been accepted by the surgical world as a substitute for other measures even in cases best adapted for the operation^ although it cannot be denied that a radical cure has sometimes been obtained^ and that in many other cases life has been prolonged beyond what could have been hoped for by any other means of treatment. It is no less true that the operation is one of great danger, and that there are not lacking those whose experience has led them to believe that life was rather shortened than lengthened by it. By these it is claimed that in lumbar colotomy we have a safer method of relieving pain, and delaying the progress of the growth, and in both these ways prolonging life. American and British surgeons hold rather to this latter idea, while the French and the Germans favor excision. Excision can scarcely be judged in comparison with colotomy, being applicable properly only to an entirely different class of cases. In cancer above four inches from the anus, colotomy or colectotomy are about the only means of relief. In cancer within four inches of the anus almost any other plan of treatment is preferable. This leads me to call attention to another point — the operation of excision as a palliative measure. In cases properly, chosen, where the disease is not so extensive as to render its removal one of the capital sur- gical operations, we know of nothing better, and this fact cannot fail to be deeply impressed upon the reader of these cases. The statement that all suffering was relieved is almost invariable. In almost every case at- tention is called to the great improvement in general health, the loss of pain, and the increase in strength. Patients go away believing them- selves radically cured, return to their employments, and are reported by the French surgeons as ^^parfaitement gueries" a few weeks after the operation. * It has been claimed' against this operation that even when a good immediate result is obtained, it may shorten life by hastening the return and final progress of the disease. Unfortunately, it is difficult to tell in any particular case how long a patient would have lived had the disease been left to its course; but, accepting as a basis for comparison Ailing- ham's estimate of the average duration of life in cancer of the rectum as two years or less, we are justified in concluding that in all cases where 1 Labbe, Gaz. Hebdom., June 4th, 18th, 1880. 236 DISEASES OF THE BBOTCTM AND ANUS. life was prolonged more than one year and a half after the time of opera- tion (the operation generally being done late in the disease)^ this length of life may fairly be attributed to the surgical interference. This esti- mate is manifestly a small one^ for a study of the cases makes it evident that many who did not live eighteen months after the operation yet gained a considerable length of comfortable existence; and there is noth- ing to prove that in any case the operation hastened the natural course of the disease. I have carefully searched the record of cases in which a return of the disease within six months of the time of operation is reported^ to discover whether^ here also^ there was any marked relation between this result and the nature or extent of the disease at the time of operation; but it is especially at this point that the table fails us. A proper answer to this question involves not only a careful report of the extent of the disease, but a microscopic study of its character, and such data are given only in a relatively small proportion of cases. I belieye, however, that the cases show a marked relation between the rapidity of the growth before operation and the speedy return after