CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 11)

In this way the diagnosis between a benign polyp and a cancerous nodule in the wall of the rectum is generally easy. But there is a class of tumors which occupy the border line between the benign and the malignant, in which the dignosis either clinically or with the micrscope may be difficult and even impossible. In fact recent careful study of these rectal tumors goes far to break down the lines be- tween the varieties which are usually drawn, and Cripps,* who has done such careful and valuable work in this department, is inclined to group nearly all of them under the single head of adenoma, holding that all are primarily affections of the glandular element. The true nature of the growths may perhaps best be gleaned from a comparison of Fig. 52 with Fig. 45, the latter being a benign polypus, and the former a malignant growth, but both being adenomata. According to Gripps the names malignant, semi-malignant, and simple adenoid will cover both the benign and cancerous growths of this part of the body, except possibly the form of colloid. Generally, but not always, it is possible to distinguish between them both clinically and microscopically. After speaking of the innocent growth which is soft, has a fairly 1 Cancer of the Rectum, London, 1880. Also Adenoid Disease of the Rectum* Trans. Path. Soc. of London, 1881. CANCEE. 21 & marked pedicle, and projects into the cuTity of the bowel, he Bays: " In the more malignant vftrieties, the new growth frequently spreads as a thin layer between the muscular and mucous coate. In this form it often occupies several square inches of the bowel, while its thickness does not exceed a quarter of an inch. At first the mucous membrane lies iutact over such a layer, but eventually it gives way by ulceration. This ulcer- ation sometimes begins at more than one point, so that the mucous mem- brane becomes honeycombed, and portious of the subjacent growth may even sprout through it. The destructive process not only destroys the mucoua membrane over the surface of the growth, but after a while the new growth is itself destroyed by ulceration. While destruction is pro- ceeding toward the centre, the growth is advancing towards the circum- ference. In this way a crater-like mass of disease is produced, the centre of which consists of dense fibrous tissue belonging to the muscular coat of the bowel, which appears for long to resist the ulcerative process. The Bto. 99.— CSDcer of the tectum— UaUgnaut Bdeuoma (Stimson). margin of the crater consists of the mucous membrane of the bowel, heaped up by the extending growth beneath it, tucking it over in such a manner as to overlap the healthy membrane. The border is at times so irregular as to represent a series of nodules rather than a continuous line." Stimson ' has also made a careful study of these growths. He says: " If it is admitted that cancer of the rectum is essentially a glandular or epithelial affection, one having its origin in the mocous membrane, the borders of the growth, as being the freshest, most recent portions, must be examined, as in carcinoma of other organs, for evidences of primary changes and mode of development. These changes consist of hypertrophy of the mucosa by hypertrophy and hyperplasia of its epithe- lial elements, together with an abundant development of embryonal connective tissue between the tubules. They are the same as those found in a variety of neoplasm of recognized benign character known as polyp ' A Contribution to the Study of Cancer of the Bectum, Archives of Hedi- ■ cine, August, 1879. 220 DISEASES OF THE BEGTUM AND ANUS. of the rectum or pofypoid adenoma. The formation of a pedunculated growth with a tendency to isolation in the one case, and of a flat growth with a tendency to spread laterally and into the underlying tissue in the other, may be explained partly by mechanical causes and partly by the degree of intensity of the changes in the submucous connective tissue. If the primary change occupies a limited area upon a natural fold of the mucous membrane, and if the muscularis mucosae remains unbroken until the young embryonal cells produced below it, in conse- quence of the neighboring irritation, have had time to develop into adult fibrous tissue, the natural retraction of this new tissue narrows the base of the fold, giving it at once a polypoid form and opposing by its greater density a stronger barrier to the extension of the epithelial formation in this direction. The pedicle once formed, the neoplasm increases in the direction open to it, that is, into the lumen of the canal in all its diameters, and the dragging to which it is subjected by the constantly recurring passage of the fsBces lengthens its pedicle and tends towards its final separation. " On the other hand, if a broader area is occupied by the primary change, or if the processes are more intense and rapid, the pedunculation is absent or less perfect, and the epithelial growths of the mucosa break through immediately, or after an interval spent in overcoming the greater resistance offered by the partial pedunculation, into the sub- mucous tissue. Once established in that region the spread of the disease is easy, and its ultimate generalization a question only of time. "The second and final barrier to generalization is presented by the muscular coat of the intestine, but it is a barrier in which are many gaps, large ones along the lines of the vessels, and innumerable small ones in the fine meshes of connective tissue which separate the muscular bundles and are continuous with the submucous tissue on one side and the para- rectal tissue on the other. Here, too, the intensity of the process materially affects the rapidity of its extension, for if the proliferating connective tissue, which is most easily implicated while it is in the formative stage, is allowed time to reach its full development, to become fibrous, it forms, as it were, a second line of defence capable of offering a certain resistance after the first line has been carried." With a full appreciation of the importance of the conclusions which Gripps has reached, it may still be well, in a work of this kind, to call attention to some of the clinical characters of some of the different forms of malignant disease as found in this part of the body. Of all the varieties of true cancer, the one most frequently met with is epithelioma, and this presents itself, here as elsewhere in the body, under two forms distinguishable with the microscope and clinically. The first (cancroid, lobulated epithelioma) contains the characteristic onion-like nests of squamous epithelium, and is the same form so commonly seen in the lip, though rarely about the anus. It has its point CANOEB. 221 of origin at the anus, and not within the rectum, and begins as a hard, dry, warty nodule. It is slow in progress, covered at first with firm epi- dermis, and only begins to ulcerate late in its course. It seldom spreads far up the rectum, but tends rather to involve the integument, which it may destroy to an extent similar to that sometimes seen in the same variety of disease about the face. In the other variety (cylindrical epi- thelioma), the celk are columnar, and the growth resembles in minute structure the mucous membrane from which it springs. This variety, on the contrary, chooses the rectum proper for its development, and is found above the internal sphincter. It is easily distinguished from the former, but not so easily from a scirrhus which has begun to ulcerate. It is softer than the other, more vascular, and therefore more prone to bleed and undergo extensive degeneration and ulceration; and it rapidly infil- trates surrounding tissues. Early in its course it is movable on the subjacent tissues, but it is seldom seen by the surgeon at this stage. At a later period it presents itself as a soft, friable mass seated on a hard, infiltrated base; ulcerated in spots, the edges of the ulcers being hard and raised. At this stage the growth will yield on pressure the well- known cancer juice containing cells and nuclei, and it may be difficult to distinguish it from a tumor which began in the submucous tissue as a hard mass, and subsequently underwent degeneration. Next to epithelioma, scirrhus, or hard cancer, is the variety most frequently met with in the rectum. It arises, not, like epithelioma, in the mucous membrane, but in the submucous connective tissue; there- fore in the early stages of its growth the membrane is found normal and movable over the hard mass beneath. When cut into it shows the characteristic, raw potato-like hardness of scirrhus, and there is no dis- tinct line of demarcation between it and the adjacent tissues. From the original tumor are often seen, and sometimes felt, hard fibrous bands spreading out in various directions, generally longitudinally in the bowel — the processes or claws from which cancer takes its name. These tumors may soften down in parts and slough or ulcerate away. When ulceration has begun, a cavity with an irregular outline is formed in the midst of the hard cancer tissue, from which issues a fetid discharge mixed with more or less blood and pus. Although a large part of the growth may die in this way and be discharged, the steady increase in the disease is not checked. Indeed, the growth often seems to be most rapid in the bed of the part which has been destroyed. This form of cancer is said to be most apt to show itself first on the anterior wall of the rectum, near the prostate,* and ''to increase most on the side of the chief arterial supply, and in that toward which, by lymphatics and veins, its constituent fluids most easily filter."* It ' Allingham, Molliere. s Moore, see Bryant's Surgery. 222 DI8BASES OF THE BEOTUM AND ANUS. spreads by infiltrating all the adjacent parts^ eyentually involying all the coats of the bowel, and extending both in surface and in thickness till, instead of appearing as a hard, moyabie spot under the mucous mem- brane, it inrolyes a great part or the whole of the circumference of the rectum, inclosing it in a dense, contracting sheath. The hardness and contractility of this form of disease are the chief clinical facts upon which a diagnosis rests; and yet, leaying out of consideration the history of the case, it will often be impossible to distinguish between the gross appear- ances of scirrhus and those of simple fibrous stricture. I have now under treatment, at the Infirmary for Diseases of the Bectum, a case of stric- ture which I believe to be dysenteric in origin, in which the extent of the disease is fully as great as in any hard cancer I have ever met with, and yet which has been eighteen years in developing. Encephaloid has its primary seat m the glandular tissue of the mucous membrane. It is inclosed m a capsule of connective tissue, from the internal surface of which spring trabecule which divide the mass into lobules. On section, it may be comparatively firm or nearly fluid, and almost white or stained red with blood. It is often very vascular; large vessels may sometimes be seen on its surface, and large blood extravasations may be found in its interior. The name fungus haematodes had been applied to a variety of this disease in which, after the capsule has burst, the mass has protruded. The material composing it may resemble brain tissue (from which it is named), or it may bo more spongy and shreddy, like placenta. On squeezing a section of the tumor, a large amount of juice may be obtained, and this, when thrown into a vessel of water, is uniformly diffused through it, giving it a milky hue. This is given by Paget as an exceedingly valuable rough test of the nature of the growth. These cancers are rapid in their increase, and may attain an immense size, fairly filling the pelvis. They quickly affect the neighboring lymphatics, and, when enucleated, speedily recur. The results of removal are, however, particularly favorable for a short time, as shown by the immediate improvement in the general condition of the patient, and the disappearance of the cancerous cachexia. The extreme softness of the tumor, and the deceptive sense of fiuctuation imparted to the finger, may cause a mistake in diagnosis, which may be avoided by the use of the aspirator, or even the hypodermic syringe. When the fiuid thus obtained is examined under the microscope, it will be found to contain cells and nuclei, with more or less blood. In colloid cancer (alveolar sarcoma), the structure is essentially the same as in the last viariety, except that the alveolar meshes are filled with a mucous, glue-like material, which m its most natural state is glistening, translucent, and pale-yellow. This variety of cancer has its origin in the follicles of Lieberkiihn, or the crypts which surround the rectum. It is not very rare in this part, and appears in the shape of large, lobulated, fungus-like tumors, which are soft and easily broken down. Under the CANOEB. 223 microscope, the mucons contents of the alveoli Vill be seen to contain cells of various forms, the most characteristic being large, round, and flat, with a nucleus and concentric lamiuas. The growth rapidly infil- trates the surrounding tissues, and secondary deposits will often be found in the neighborhood of the original mass, the whole tending to undergo cystic degeneration. The malignancy of these tumors varies in degree, some of them being comparatively benign; they do not always recur after removel, nor do they readily infect the lymphatics and viscera, being in this respect about on a par with epithelioma. The term colloid is used without much exactness, being applied to almost any growth which consists in part of large, cellular spaces filled with glue- like material. The following description of a case illustrates very per- fectly the general characteristics of colloid: Case XXII. — " The patient was an old woman, and the case was peculiar, in that the colloid material was contained in cysts of various «izes, pressed firmly one against the other, so that the disease might be called multiple cystic colloid degeneration. The anus was surrounded with a large number of tumors of unequal size, of which several, larger than the rest, were surmounted by smaller ones m such a way that the anus occupied the bottom of an extremely deep infundibulum. Two superficial ulcerations were to be seen at the margin of the anus. The finger recognized at a shoi*t distance above the anus an ulceration in the form of a zone, which was deep, had destroyed all the thickness of the rectum in a part of its circumference, and communicated with fistulous tracks, which penetrated into the substance of the diseased skin adjacent to the anus. The degeneration, which had given the rectum an enormous thick- ness, ceased abruptly nine or ten centimetres from the anus. Immedi- ately above, the rectum presented considerable hypertrophy in the muscular layer. This affection, which had all the characters of colloid degeneration, presented an arrangement in its upper two-thirds which I had never before met with, and which I will try and describe. Let one imagine a number of acephalocysts of unequal size (some of them as large as pigeons' eggs) squeezed firmly one against the ' other, and held in a fibrous network, and one will have an exact Idea of the change. Only these were not acephalocysts. The covering of each cyst was fibrous, Tery thin, and yet very strong ; the matter contained in them exactly resembled currant jelly, on the surface of which had been deposited a cretaceous matter exactly similar to that which sometimes covers the excrement of birds. This cretaceous matter contained calcareous con- cretions. In the centre of the jelly-like substance, two or three blood- Tessels were to be seen, similar to those which form in a hen's egg — vessels without walls, ending in an enlargement of one extremity. The fibrous network in the midst of which these cysts were inclosed was evidently made up of the transformed coats of the rectum. I could 224 DISEASES OF THE RBOTUM AND ANUS. recognize the longitudinal fibres of the rectum. There was also adipose tissue^ an evident proof that the degeneration had not only invaded the rectum^ but had developed at the expense of the adipose tissue of the pelvis. The lower third of the rectum presented no sign of a cyst, but an areolar tissue^ with fibrous meshes, which occupied all the circumference of the anus; this tissue was filled like a sponge with colloid matter, which could easily be pressed out^ and the tissue itself was approaching erosion or ulceration. The areolar and gelatiniform degeneration appeared to me to penetrate into the thickness of the skin of the anal region; while an extremely thin, almost epidermic, pellicle had resisted and covered the swellings on its surface. In the vicinity of the circular ulceration of the rectum, the colloid matter had not undergone degenera- tion, only it was permeated by an increased number of blood-vessels. Behind the rectum was a colloid alveolar mass, all the areolae of which contained blood-vessels. This mass had evidently been formed at the expense of the circum-rectal adipose tissue.'" Gruveilhier draws this distinction between colloid and encephaloid. The colloid degeneration is not susceptible, as is the encephaloid, of inflammatory action producing gangrene; moreover, if the sanguineous centres are not absolutely foreign to it, it is certain that they are incom- parably rarer in colloid than in the cancerous degeneration, properly so called, where effusions of blood are so often met with — apoplectic centres sometimes so large as to