This section is from the book "Diseases Of The Intestines", by Max Einhorn. Also available from Amazon: Diseases Of The Intestines A Text-Book For Practitioners And Students Of Medicine.
The general symptoms of cancer of the bowel are those found in malignant growths of other organs. Of these anaemia and cachexia are the most important. Usually both are present at the same time. Sometimes one is more pronounced than the other. In some instances a general weakness, pallor, and emaciation are the first indications of a severe affection. There may be as yet no local symptoms whatever or a very slight degree of constipation and scarcely noticeable sensation of discomfort in the abdomen. Loss of appetite and slight dyspeptic symptoms are often encountered. Fever is occasionally met with, which is due to a suppurative process and absorption of pyogenic matter into the blood. The neoplasm often gives rise to disturbances in neighboring organs by constricting or dragging upon them. Thus radiating pains from compression of nerves may arise and in the same manner disturbances of circulation. (Edema of the lower extremities is often encountered, which after lasting for weeks and months may occasionally disappear shortly before death.
Symptoms of chronic intestinal obstruction are often present. They develop either gradually, the constipation increasing more and more, or they may appear more abruptly. The bowels, while formerly more or less regular, suddenly cease to move, and even strong cathartics are of no avail.
The clinical features of cancerous obstruction of the bowel are not different from stenosis of the intestine caused by other processes, which are described in Chapter IX (Acute And Chronic Intestinal Obstruction). Such a sudden attack of obstruction of the bowel may terminate fatally in a few days; sometimes, however, after a total occlusion of the bowels, life continues much longer. Thus fecal retention of forty-four days' duration, without even fecal vomiting, is mentioned by Heusgen,1 and another case of eighty-eight days' duration has been reported by Cooper-Forster.2 Diarrhoea is frequently present in cancer of the bowels. This often serves partly to overcome the beginning obstruction of the intestinal lumen. In some cases diarrhoea alternates with constipation. In the latter instance the stools often bear signs of having passed a strictured spot. They may appeal in the shape of a tape or in the form of small, hard balls. These characteristics of the evacuation are, however, by no means a positive proof of a real stricture, for they are also met with in merely neurotic conditions. The stools often contain an admixture of mucus, blood, or pus. In case the progress of the necrosis of the neoplasm is pronounced, the stools during that period have a very offensive, almost unbearable odor.
In rare instances particles of tumor may be discovered in the dejecta, which show under the microscope the exact nature of the neoplasm. If these particles are of a large size (cherry or walnut) they will be easily discovered in the stools; but if they are minute, a thorough examination of the fecal matter will be necessary in order to find them. Washing out of the bowels will often be helpful to discover such minute pieces of the growth, in case the latter is situated in the colon.
1 Heusgen: Deutsche med. Wochenschr., 1877
2 Cooper-Forster: Medical Times and Gazette, September, 1867.
While all of the above symptoms are of great value, they are unimportant compared with the physical signs of a tumor. Its presence in a doubtful case in most instances helps to clear up the diagnosis. The tumor is often easily palpable and bears the general characteristics of a cancerous growth. It is hard and presents an uneven nodular surface. Its size varies greatly, being often that of a walnut and occasionally that of an apple or still larger. In the latter instance the mere inspection of the abdomen may already show the presence of the tumor. In autopsies the neoplasm is frequently found much smaller than it appeared to be during life. The cause of this is the hypertrophy which occurs in the walls of the bowel above the tumor, together with the accumulation of fecal matter at the same place. The tumor is usually situated in the lower half of the abdomen, principally in the left iliac region, not only because this part of the intestine is so often affected, but also because a neoplasm of other parts of the bowel, if not fixed by adhesions, is as a rule dragged down by its own weight into this region. Intestinal neoplasms as a rule show a high degree of mobility. Often they can be moved with the hand in all directions in the abdominal cavity.
The only exceptions to this rule are tumors of the duodenum, the sigmoid flexure, and the caecum, which are more or less fixed.
With regard to the detection of the tumor a thorough palpation of the abdomen (if the abdominal walls are very rigid, under ether or chloroform narcosis) is necessary. A digital examination of the rectum, and, in women, of both rectum and vagina, will in most instances be required. A bimanual examination will also be found useful. In case the affected area in the rectum is not accessible to digital examination, inspection of this organ and in some instances a manual examination under anaesthesia with the whole hand must be resorted to.
When the disease is fully developed, peritonitis (either circumscribed or general) often appears as a complication. It may be simply caused by the inflammatory processes accompanying the neoplasm or be of a real cancerous nature. While at first it is impossible to differentiate these two conditions, later on it is as a rule not difficult to determine which of the two is present. The discovery of a hemorrhagic exudation and of a few nodules under the abdominal wall will indicate that a cancerous affection of the peritoneum is present. An acute perforation peritonitis is much more rare and leads to shock and sudden death, or in the presence of adhesions to grave complications in consequence of fecal abscesses. If the perforation occurs into adherent neighboring organs, new communications may be formed between them and the intestine; they aggravate the condition and are of great clinical importance. The following communications are frequently met with:
1. Fistula between stomach and colon. The fistulous opening may freely communicate with both cavities or only in one direction on account of the formation of a valve. If the passage has the direction from the stomach into the colon, symptoms of lientery develop, and undigested and unchanged foods, as for instance pieces of meat, potatoes, spinach, and the like, appear in more or less large quantities in the stools; often diarrhoea manifests itself shortly after a meal and examination of the evacuation shows numerous particles of food from the last meal. Lavage of the stomach performed in such a case will often show that the liquid has escaped from the stomach in considerable quantity and may occasionally be voided by the rectum. The admixture of some coloring matter to the water used for lavage will facilitate the recognition of this condition. If the communication has a direction in the opposite way, namely, from the colon into the stomach, there will be an appearance of fecal matter in the latter. In that event the gastric contents always contain decomposed and fetid material, and vomiting of fecal matter is frequently the result.
Inflating the colon with air will often cause a filling up of the stomach with this gas, and again irrigation of the bowel with water (either clear or stained) will be followed by its appearance in the stomach, which may be easily discovered by introducing a tube into this organ and evacuating the gastric contents. If the fistulous opening has a free communication in both directions, then symptoms of lientery and fecal vomiting may be present at the same time or they may appear alternately.
2. In case of a communication between rectum and bladder, small particles of fecal matter and gas appear in the latter organ and may be voided through the urethra. They give rise to a putrid cystitis. Occasionally urine may pass from the bladder into the rectum and be discharged with the stools. The recognition of the latter condition is, however, more difficult.
3. Communications between the rectum and uterus or vagina are also met with and give rise to the passage of fecal matter through these organs.
4. A fistulous opening may exist between the bowel and the abdominal watt. This fistula may discharge externally a putrid secretion having a fetid odor and containing particles of fecal matter or chyle, depending upon its location, whether in the large or small intestine.
All these fistulous communications appear as a rule in the last stages of the disease. They are, however, by no means characteristic of cancer of the intestine, for they may also, but very rarely, develop in consequence of other ulcerative processes in the bowel (tubercles). Again they may be a result of a cancerous growth in the stomach involving secondarily the intestinal tract.
The urine does not show anything characteristic of cancer. However, it often contains large amounts of indican; acetone and diacetic acid have also been occasionally met with.