MALIGNANT DISEASE OF THE RECTUM.* BY A. B. COOKE, A.M., M.D. Professor of Anatomy and Clinical Professor of Proctology, Medical De- Mr. President and Fellows: Malignant disease of the rectum is usually described under the good old name of "Cancer." And this name is peculiarly appropriate for the reason that the term cancer, as ordinarily understood, conveys a more or less definite idea of carcinoma. While a few cases of sarcoma of the rectum have from time to time been recorded, it occurs so rarely in this situation that no further specific reference will be made to it. Statistics show that some 3.5 per cent. of all cases of cancer are located in the intestinal tract and that more than 80 per cent. of these are found in the rectum. This would make the rectum the seat of the disease in approximately 3 per cent. of all cases a rather large proportion for any one organ. The type of the disease is determined by its site. When the anus is attacked, epithelioma; when the movable rectum is invaded, adeno-carcinoma in some one of its several varieties. With reference to etiology, it is worthy of note that study of cancer of the rectum develops strong confirmatory evidence of the idea so vigorously opposed by some that the disease is primarily a local one. When seoondary deposits occur in the liver they are found to consist of columnar cells from the rectum and gland tissue, identical in structure with the follicles of Lieberkuhn normal to the bowel at the site of the original growth. Whatever pathologists may ultimately prove to be the real cause of cancer, local irritation will doubtless continue to be *Contribution to "Symposium," read before the Tennessee State Medical Society, Memphis, April 10th, 1902. accepted as the potent factor in determining the site of its development. Considering the function of the rectum and its anatomic structure it is easy to understand the relatively large proportion of cases encountered here. The symptoms of cancer of the rectum are in no sense distinctive. At first there is merely a sensation of fullness and weight in the pelvis, local irritation, inflammation and ulceration following in the order named and giving rise to their characteristic symptoms. Tenesmus and more or less profuse pathologic discharges become the most prominent symptoms as soon as ulceration takes place. There is nothing of diagnostic value from a clinical standpoint about the discharges, unless an unusual proportion of blood be so considered. However, intelligent use of the microscope is capable of rendering great aid in this connection. The amount of pain incident to a rectal cancer depends largely upon the location of the disease. If in the anal canal the pain is generally very severe; if in the movable rectum, real pain may be entirely absent. Certain authorities have described a kind of pain peculiar to malignant disease and diagnostic of it independent of its site. But in the experience of the writer no such instance has been encountered. Obstruction to the passage of feces is less marked in cancer than in benign stricture, due to the tendency of the former to break down easily, thus keeping the lumen open. Total obstruction is comparatively rarely encountered for the same reason, metastatic invasion of other organs and exhaustion usually resulting in death before the local growth reaches such proportions. The so-called cancerous cachexia is a late development and not entitled to any great weight in the matter of diagnosis. Indeed, all diseases of the rectum marked by ulceration and irritating discharges quickly result in producing the appearance so denomitated, by reason of the associated tenesmus, loss of blood, broken rest, intestinal disturbance, malnutrition, etc. In the diagnosis of cancer of the rectum uncertainty is never excusable. The symptoms should always be carefully elicited and duly weighed, but, however characteristic they may be, our full duty is never done until a thorough physical exploration has been made. Fortunately, modern methods of examination leave no room for doubt as to the nature and extent of any dis ease located within the distal eighteen inches of the anus. In this connection I may properly enter a plea for more systematic examination of all cases of rectal disease without reference to history and symptoms. The profession cannot longer afford to rest under the imputation of criminal negligence in this respect. The onset of cancer is always insidious and in its early stages the symptoms do not differ from those of the ever popular "piles" and other diseases of this organ. The pity of it is that neglect in the early stages too often means hopeless impotence in the later stages-the possibility of successful treatment decreases with terrible rapidity as the disease advances. If physicians would only insist on seeing what can be seen and feeling what can be felt in every case that consults them, the result would be a saving of many valuable lives. For I would again emphasize that with respect to rectal disease, no man, though he possess the divination of a god, can make other than a conjectural diag. nosis from the subjective symptoms. Personally, my own invariable rule, and I believe it is the only proper one, is to decline to treat any case in which I am not permitted to make a local examination. Such a rule may occasionally be charged with the sacrifice of a fee, but in the long run it will certainly prove conducive to self-respect. When the disease has been located its nature may be determined by the history of the case, age of the patient, physical characteristics of the growth, lymphatic involvement, metastasis, and the employment of the microscrope when any doubt remains. Now, what and how much in the way of relief can be promised the victims of rectal cancer? Very little at best. From palliative measures, whether medical or operative, we can hope for nothing more than to promote the comfort and, to some extent perhaps, prolong the life of the sufferer. Radical measures likewise hold out little promise under the conditions ordinarily presented by these cases, That the latter statement is true is the most deplorable fact connected with the subject. It is reasonable to believe-indeed, clinical experience has abundantly demonstrated-that in the early stages of the disease surgery is not more powerless here than in cancer of other organs. But the sad truth must again be noted that these cases are rarely seen until lymphatic involvement, metastasis, and general ex. haustion have rendered them practically hopeless. In determining the treatment indicated in any given case, the first question to be considered is: Can the entire disease be removed? When this question is answered in the affirmative it will not often be found that the condition of the patient's general health will forbid the operation, nor will it often be declined when the nature of the disease is explained to the victim and his friends. But because, and only because, the question must be answered in the negative in such a large proportion of cases, palliative treatment demands consideration. This may be briefly disposed of. The first indication is to keep the parts as clean as possible by the use of enemas to which may be added a little carbolic acid, and if the suffering is great, a small quantity of tincture of opium. The bowels should be kept in a soluble condition by the judicious administration of laxatives and regulation of the diet. The use of opium and its derivatives should never be begun in these cases except with a full knowledge of the probable result. For my own part, in hopeless cases where the tenesmus and pain are great, I do not hesitate to give it as often and in as large quantities as may be necessary to keep the patient comfortable. That the opium habit results is a matter of small moment, for the life history of these cases rarely exceeds three years and the fatal termination is not appreciably hastened by the drug. And even if it were, the relief which can be given in no other way counts for more than an additional month or year of a miserable existence. Any operative procedure which does not contemplate the removal of the entire growth, properly considered is merely a palliative measure and should be so classed. Of these proctotomy and attacking the growth with curette or sharp spoon occasionally serve a useful purpose when obstruction is threatened. But the tendency of malignant growths to take on renewed and increased activity when subjected to traumatism, surgical or otherwise, must be constantly borne in mind in deciding upon such measures. In selected cases colostomy possesses decided advantages over every other method of treatment. Of course being strictly speaking a purely palliative procedure, this statement is predi cated on the distinct hypothesis that the growth will not permit of total extirpation. The advantages of the operation are obvious. Not only are the dangers of obstruction eliminated, but the diseased rectum is saved from the constantly recurring irritation due to the fecal discharges and made accessible to cleansing and soothing applications from above as well as from below. Clinically it is daily being demonstrated that these patients gain rapidly in flesh and strength after the operation, and that life is both prolonged and rendered far more comfortable by it. The objection sometimes urged that the patient becomes an object of disgust after a colotomy is based either upon faulty knowledge or false sentiment and is not entitled to serious consideration. The technique of colotomy cannot here be discussed. It must suffice to say that in the majority of cases the inguinal route is preferable and that to obtain the greatest benefit from the operation it should be performed early-before the patient's strength has been lost beyond the rallying point. The only truly radical treatment of malignant disease of the rectum is extirpation of the entire growth without reference to extent or the importance of the parts affected. When this cannot be accomplished it is far better not to perpetrate a useless and dangerous mutilation upon the patient. Excision of the rectum, particularly the upper portion, is one of the most difficult and dangerous operations in surgery-difficult for anatomic reasons, dangerous chiefly for the reason that it is too often undertaken without regard to the definite indications in the case. That statistics show an operative mortality of about 40 per cent. and a large proportion of recurrences are due for the most part to the latter consideration. Resorted to sufficiently early and applied sufficiently boldly, there is no reason to believe that surgery would be less effective here than in malignant disease of other parts. The proper limits of this paper forbid a detailed consideration of the several methods of operating. Broadly speaking tt may be said that when the disease is confined to the distal four or five inches it may be successfully attacked by the perineal route; when above this height the sacral route is preferable, or the two methods may sometimes be utilized to advantage in |
