CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 16)

it is easy to understand why cancer is in one person attended by excruciating suffering, while another may hardly be conscious of its presence; and why the pain is in some paroxys- mal and particularly aggravated by a movement of the bowels, and in others dull and constant, radiating through the loins and down the thighs. For the relief of this symptom we have at our command: a. Itegulation of the passage, diet, and the recumbent posture; b. Anodynes locally and by the mouth; c. Partial destruction of the growth by means of the curette, cauterization, or partial extirpation; d. Division of the sphincter; e. Lumbar colotomy. The passages should be kept soft but not fluid, as any approach to diarrhoea always aggravates the suffering. This may be done partly by 248 DISEASES OF THE BECTUM AND ANUS. the choice of food^ which needs to be regulated with great care on account of the tendency to gastric disturbance^ more or less of which ia always present; and by the administration of the mineral waters, which are generally sufficiently laxative for the purpose. Eest in the recum- bent posture is a means of palliation of great value, sometimes f^^/ig more relief than anodynes. These latter may be given both ' by the mouth and in enemata, and if possible should be pushed to the point of relieving suffering. This seems so plain a duty which the surgeon owes to bis patient, that we need not stop to discuss any possible moral bear- ing it may have. If the agony of this incurable malady could always be relieved by the administration of opium, the question of operative inter- ference would arise much less frequently than it now does. But, unfor- tunately, the constant administration of this or any other narcotic will sometimes cause gastric and mental disturbance, harder to bear than the disease. By using the finger-nail, a curette similar to the one used in the uterus, or a scoop such as is used for submucous uterine tumors, the pain may in some cases be greatly relieved by a removal of a part of the growth when of the soft variety. The same may be done by the applica- tion of chemically destructive agents or the actual cautery, and even by the partial excision of the mass, merely as a means of relief and where there is no question of cure. I have already called attention to division of the sphincter muscle as a palliative measure in the treatment of rectal disease, and all that was said regarding the treatment of benign stricture applies equally well to cancer. The dernier ressort of surgery for the relief of pain is lumbar colot- omy. "We have already attempted to limit the scope of this operation. In any case in which the suffering is due to the direct contact of faeces with the diseased surface, and is not due to a spasmodic action of the sphincter muscle, and cannot therefore be relieved by the permanent division and paralysis of that muscle, and is not due to the extension into and pressure of the disease upon neighboring parts, the operation may be tried. There may be such cases, but they are not common — not nearly as common as is lumbar colotomy for cancer. Let it be remem- bered, however, that after colotomy faeces will still find their way to the tender point, and that the amount of suffering from a small mass of faeces may be as great as from the entire quantity. "With regard to husbanding the sufferer's powers and prolonging life, much may be done by careful nursing and medication. Milk is by far the best diet, and cod-liver oil in small doses the best medicine where it can be borne, for it has a laxative as well as a tonic action. Cleanliness is best obtained by frequent washing out of the rectum with disinfecting fluids, as permanganate of potash and carbolic acid. The means of overcoming obstruction in malignant disease are also much the same as in benign stricture, and to what has already been said on that subject we must again refer the reader. Before commencing to CANCER. 249 treat the obstruction as such, it is well to remember that an exceedingly small outlet to tlie alimentary canal may, with proper care, be made to answer all the calls of nature. We see this constantly in cases of stric- ture both simple and malignant, where the finger cannot be forced through the obstruction, and yet there is no retention; and in such cases, by the judicious administration of laxatives, life may be made so comfortable that the question of surgical interference shall be postponed indefinitely. When, howeyer, obstruction is actually threatened, much may be done by the medical means already pointed out. When dilatation becomes necessary, it should be of the gentlest kind. The cases of fatal accident from perforation of the bowel where the coats have been weakened by ulceration are already numerous enough to serve as warnings for all future time. The best of all dilators in cancerous disease is the finger, either that of the patient or the nurse, passed daily; and none of the mechanical means with which we are acquainted equals this for safety and comfort. When the disease is beyond the reach of the finger, a bougie must be "used, but the dangers are greatly increased, and it may be better at once to make an artificial anus than to incur the risk of fatal accident which the use of a bougie high up the bowel certainly entails. The frequency with which thq bougie may be used will depend upon the result of its trial Should much irritation, tenesmus, or haemorrhage follow its em- ployment, the patient will soon refuse to submit to its continuance; while, on the other hand, should the result be favorable, it may be em- ^mployed daily. The softest bougie is the best, and a candle often an- swers admirably. If dilatation be found too painful or ineffectual, as it sometimes will, recourse may be had to division or partial destruction of the cancerous mass. A double proctotomy may be done in case of malignant disease, and the section of the growth between the two incisions be removed, in this way opening once more the calibre of the bowel and overcoming the obstruction. I have performed this modified operation with great relief, and I have also found that, after making a single free division of the cancerous mass, large pieces adjacent to the cut could be excised with great facility and without danger. The latter operation is rather the preferable one. Belief both to pain and obstruction may sometimes be gained in this way by a partial destruction and extirpation of a cancerous growth, where its entire removal is out of the question, and its local return may be expected with certainty. By such measures, the evacuations may be made less painful, the spasmodic action of the sphincter and the rec- tal tenesmus may be allayed, the cancerous look may for a time disap- pear, and the patient recover sufficient strength to resume the ordinary occupations of life. A growth may be attacked in this way, either with the knife, cautery, 250 DISEASES OF THE RECTUM AND ANUS. « finger or curette. Caastic applications are of no use, except in case? where a fangons mass has protruded from the anus. This may, at times, be removed with great advantage to the sufferer, by the applica- tion of a paste of arsenite of copper, mixed with mucilage. The opera- tions for removing a part of the growth with the finger, scoop, or curette may give great relief in the soft varieties of the disease. The sphincter should first be thoroughly dilated, the anus held open with a speculum, and as much of the diseased tissue as possible torn and scraped away. Haemorrhage, of course, is to be expected, but this is less where the growth is boldly attacked in its deeper parts than when the surgeon is timid and attacks merely the superficial portions; and maybe controlled either by plugging the wound with lint and styptics, or by the actual cautery. AUingham relates a case in which he entirely enucleated an immense encephaloid with his hand, with the happiest results. As a substitute for partial destruction of the growth in this way, the operation of crushing with an instrument similar to the enterotome of Dupuytren has been proposed. The proceeding is only applicable to a. certain class of cases, in which the stricture is annular and not too ex- tensive to be grasped by the instrument, and has no advantages over the other methods. There is no obstruction within four inches of the anus which may not be overcome by some one or other of these means. What, then, remains for lumbar colotomy ? Simply those above the reflection of the perito- neum. It will often be difficult for the surgeon to decide for or against, colotomy in these cases. Two factors enter into the question: 1st, whether or not the patient is likely to survive the operation itself; and, 2d, if this is decided in the affirmative, whether sufficient is to be gained to pay for the risk. The general condition of the patient, the extent of disease as regards secondary deposits, and the amount of pain dne to de- fecation, all have to be taken into consideration. The operation may be^ indicated to relieve this pain when there is not much chance of actually prolonging life, and it may be indicated to prevent or overcome obstruc- tion where there is no great amount of pain. I am inclined, for myself, to limit the operation to those cases where the pain of defecation is great, and where the disease is still circumscribed, and should not for the choice between death from obstruction and death a few weeks later from exhaustion always have recourse to this extreme measure, but should rather trust to securing a comparatively easy passing away of the patient under the influence of opium. Indeed, many patients will decide the question in this way for themselves when it is explained to them in all its- bearings. It is a curious fact that, by relieving the over-distention of the^ bowels by colotomy, the obstruction also will sometimes cease, and pas- sages will again pursue their natural course. Such a case is reported by CANCEB. 251 Ooodhart^ where three successive operations for opening the colon above the stricture were resorted to to relieve obstruction, and after each one the passages were again restored to the natural outlet. This hook is the property/ of COOPER MEDICAL COLLEGE, SAN FRANCISOO, CAL. ami ?>' 'n(»f to hi^ Ti'iVjyrr.Oj from the Lil'r(fi,i /'•> I I',/ (' ij jxrsou or 252 DISEASES OF THE BECTUM AND ANUS.