(D) Cancer Of The Rectum

The symptoms met with in cancer of the rectum resemble more or less those of a neoplasm of the upper portion of the large bowel. Here, however, the diagnosis can be made with greater ease and certainty. In most instances rectal cancer can be discovered by a digital examination of the rectum. By means of the latter we may discover a mass lying right beneath the mucous membrane of the rectum, over which the mucosa can be slightly moved or not at all if it is adherent. The surface may feel uneven and somewhat hard. Sometimes the finger encounters a constriction through which it cannot easily pass; the tissues here present the same characteristics as just described. Occasionally an ulcerated area 11 can be discovered on the surface of the neoplasm. In cancer of the rectum situated high up (not accessible to digital examination), several clinicians have advised examination with the whole hand passed through the rectum. This, however, can be done only under chloroform narcosis and is not free from danger.

Such an examination may in rare instances cause rupture of the intestinal wall as stated by Volkmann.1 Inspection of the rectum by means of Kelt's speculum can be easily performed and aids us in discovering a neoplasm situated quite high up in the rectum, even if not accessible to digital examination. The latter instrument may also be used in neoplasms of the lowest part of the bowel, although its use here is not of much importance, as the palpating finger gives us enough certainty in making the diagnosis.

Cancer of the rectum is as a rule accompanied by severer pains than that of the large bowel. These as a rule are local in character. They often radiate toward the caecum and the lower lumbar region, toward the bladder and genital organs, and sometimes in the direction of the sciatic nerves. In case the neoplasm involves the anus, there is an exacerbation of the pain at each evacuation. Tenesmus is constantly present in the latter instance. If such a neoplasm of the lower parts of the rectum becomes ulcerated, the tortures of the afflicted person can hardly be described. The patient as a rule is afraid of having an evacuation, and tries to keep it back as long as possible. At last there is a movement containing fecal matter, mucus, blood, and sometimes pus, under most excruciating pains.

Leube has directed attention to the fact that hemorrhoids are frequently associated with the neoplasm of the rectum. Tins is of importance, as it shows that the presence of hemorrhoids should not lead one to abstain from digital rectal examination. If a patient has complained of constipation for a short period (a few months) and hemorrhoids have developed during this time, the latter are rather indicative of a more serious condition, and a digital examination of the rectum should always be undertaken under such circumstances.

1 Volkmann: "Ueber den Mastdarmkrebs." Volkmann'sSammlung klin. Vortraege, No. 131.

Course

An uncomplicated intestinal cancer may last for years. Frequently, however, the time is much shorter. Many complications are liable to occur - hemorrhages, perforation peritonitis, rupture of the intestines, ileus, autointoxication, extension of the cancer to other organs, and metastases. On account of these many possibilities the life of the patient may be shortened, and it is hardly possible to foresee its duration. In some instances a condition of coma (coma carcinomatosum) appears quite earl}-. It is generally assumed that the latter is due to auto-intoxication, either by the products of decomposition of the intestinal contents or by the toxins of the cancer. Ewald in such a case succeeded in isolating a body from the urine belonging to the group of diamins. In cancer of the duodenum the general nutrition suffers very early and extensively, and for this reason the duration of life is short. In cancer of the rectum nutrition is well maintained for a long period, and for this reason the duration of life in the absence of complications is quite long (about four years). In case anaemia of a high degree supervenes, a marasmic thrombosis may develop and the patient may die in consequence of an embolus of the lungs.

If intestinal cancer is unattended with complications, death often results in consequence of general exhaustion.