Part 146

SURGICAL TREATMENT.--In cases of acute obstruction of the bowel from bands of lymph, diverticula, internal hernia, slipping of a portion of gut into some opening, or twisting, when the treatment suggested has been tried and fails, laparotomy should be performed; that is, the abdomen should be laid open, the cause of the obstruction searched for, and, if possible, removed. In acute cases a few hours, at most one day, may be spent in trying the medical means recommended. After that time, if the patient is not relieved, the sooner laparotomy is resorted to the better the chance to save life. Acute internal strangulation of the bowel from these causes has the same symptoms, course, and termination that acute external strangulated hernia has. It demands the same treatment--removal of the cause of the constriction. Delay in performing the operation in the former is as certain to be followed by peritonitis, gangrene, and death as it is in the latter; and the surgeon who hesitates to open the abdomen and attempt to remove the constriction in a case of acute obstruction after a fair trial and failure of medical measures, is as culpable as the one who delays the operation of herniotomy for unrelieved strangulated hernia.

In rare instances spontaneous self-reduction of external strangulated hernia takes place; the cases are exceptional, and the fact is no apology for postponing herniotomy. So in occasional instances acute internal strangulation is spontaneously relieved; here too the cases are exceptional, and the occurrence should be no excuse for delay in laparotomy. To justify the operation it is not necessary that the precise site and nature of the mechanical impediment should be determined, although this can usually be done. It is only necessary to know that the cause of the acute obstruction is not enteritis or peritonitis, but a constriction mechanical in character, which no medicine or manipulation or expectant treatment can relieve. When diagnosis is clear and laparotomy is indicated to save or prolong life in intestinal obstruction, the aid of the surgeon should at once be invoked. Delay is fatal. Peritonitis beginning or in actual existence makes abdominal section more dangerous and {866} lessens materially the chances of recovery. To make the operation absolutely the last resort when the bowel is injured beyond repair, when peritonitis is in full progress, gangrene threatening, or the patient on the verge of collapse, is a useless cruelty to the sufferer and his friends, and only serves to bring surgery into disrepute. If the truth were known, many of the cases of death following laparotomy should be ascribed not to the fact that the knife was used, but to the fact that it was used too late.

In intussusception not relieved by medical means the propriety of abdominal section is questionable. The subjects of this condition are usually children. Dislodging the invaginated bowel is not always practicable, and the opium or expectant treatment may end in spontaneous cure by the bowel righting itself or by sloughing of the intussuscepted part. It is doubtless true that many of the so-called cures from the latter process subsequently die from contraction of the cicatrix at the site of the separation of the slough. In 43 cases collected by Ashhurst of laparotomy for invagination, 13 recovered and 30 died. The record is bad, and to some extent the heavy mortality is due to the fact that the operation was put off too long--delayed in acute cases until sloughing had taken place, and in chronic cases until adhesion of the invaginated parts had occurred. Indeed, some of the cases reported were moribund when the operation was undertaken. Recently many successful cases have been reported, and it is fair to presume that the percentage of recoveries in the future will be greater than they have been in the past.

In acute intestinal obstruction due to bands, internal hernia, volvulus, or the presence of foreign bodies, as gall-stones, there is no question that laparotomy should be performed after other measures for relief have been employed and failed. Death in such cases is inevitable and imminent, and operative interference should not be postponed until peritonitis has set in. After the abdominal cavity has been opened the distended gut can easily be found and the fingers of the operator carried on down until the site of the constriction is reached and the cause of the obstruction discovered. If the constriction is due to the presence of bands or adhesions, they should be cut or broken up and the gut relieved. If an internal hernia is found or a portion of bowel has slipped into some fissure or pocket, it should be withdrawn and the parts restored to their natural position. If the cause of the obstruction is a volvulus, the bowel should be untwisted. If a foreign body is felt impacted in the bowel and closing it, unless it can be readily and without danger of lacerating the coats of the gut pushed on by the fingers of the operator until it has passed the ileo-cæcal valve, the foreign body should be removed from the bowel by an incision and the wound in the bowel afterward closed by sutures. If the case is one of intussusception, the invaginated parts should be pulled out: this is practicable where adhesions are absent or slight, but if the adhesions are very firm, and it is impossible to restore the parts to their natural position, the gut should be laid open above the occlusion, the edges of the opening should be attached to the margin of the external wound, and a fecal fistula established. If the case of acute obstruction be due to stricture of the small intestine, which is exceedingly rare, the gut may be laid open, and the patient recover with fecal fistula, or entorectomy or resection of the diseased part of the gut be resorted to. The operation of entorectomy has been recommended by many {867} surgeons, and a large proportion of the cases reported recovered. In one case by Koeberle six and a half feet of the gut were successfully excised.

The following table by Ashhurst shows the results of laparotomy. It will be seen that in 230 cases 68 recovered:

| | Result | | | | not | | | | ascer- | Recov- | | Cases. | tained. | ered. | Died. ---------------------------------+--------+---------+--------+------ Operations for-- | | | | Volvulus | 14 | 1 | 4 | 9 Strangulation continuing after | | | | herniotomy or taxis | 18 | ... | 6 | 12 Invagination | 43 | ... | 13 | 30 Foreign bodies, impacted | | | | feces, gall-stones, etc. | 18 | 1 | 7 | 10 Strangulation by bands, | | | | adhesions, or diverticula | 76 | 1 | 20 | 55 Obstructions from tumors, | | | | strictures, ulcers, etc. | 28 | 2 | 7 | 19 Internal hernia and ileus | 20 | 1 | 7 | 12 Obstructions from other causes | 4 | ... | 1 | 3 Causes of obstruction not | | | | ascertained | 9 | 1 | 3 | 5 ---------------------------------+--------+---------+--------+------ Aggregate | 230 | 7 | 68 | 155 ---------------------------------+--------+---------+--------+------

Enterotomy is an operation originally performed by Nélaton. It is done by making an incision, preferably in the right groin, above the crest of the ileum and parallel with Poupart's ligament. When the abdomen is opened a coil of intestine is found and carefully stitched to the walls of the incision. A very small opening is then made into the bowel, and a fecal fistula established. Enterotomy is less dangerous than laparotomy, as by it there is less interference with the peritoneum; but no relief could be afforded by this procedure in cases of intussusception or acute obstruction from bands, hernia, or volvulus. It is applicable to cases of intestinal constriction when the obstruction is about the lower part of the small or upper part of the large intestine. It may be resorted to as a palliative measure when exact diagnosis as to the character and site of the obstruction is not clear, the case being otherwise hopeless, or in cases of obstruction where severe symptoms persist and death is near, and yet for any reason laparotomy or colotomy is inapplicable; or it may be performed in cases of contractions after failure of patient and persistent medical treatment. Many successful cases of enterotomy have lately been reported, and the operation has been earnestly advocated by Trousseau, Maunders, Wagstaffe, Bryant, and others. In chronic constriction due to stricture or other mechanical obstructions, malignant or otherwise, not remediable by any medical measures, colotomy should be performed. By this operation the colon is opened and an artificial anus established. The sigmoid flexure in the left lumbar region is the part selected for the colotomy if the obstruction is situated in the gut below that point. When the obstruction is higher up in the colon or its exact site cannot be determined, the cæcum in the right lumbar region is the part chosen. In cases of obstruction from the mechanical pressure of tumors, the possibility of relieving the compressed bowel by treating the tumors should of course be considered before resorting to colotomy.

{868}

CANCER AND LARDACEOUS DEGENERATION OF THE INTESTINES.

BY I. E. ATKINSON, M.D.

The term cancer of the intestines is used here in a clinical sense to designate new formations in the intestinal tract the tendency of which is to destroy life, and has no reference to the histological characters of the tumors, inasmuch as these are, during life, for the most part, concealed from the eye of the pathologist. It so happens, however, that in a histological as well as in a clinical sense the term is appropriately applied to all but a very few of the malignant new growths that develop in the parts under consideration, if we adopt, as seems proper, the opinion of most modern pathologists, that cancer or carcinoma should only include those tumors "consisting of cells of an epithelial type, without any intercellular substance, grouped together irregularly without the alveoli of a more or less dense fibroid stroma."

Carcinoma of the intestines appears either as cylindrical-cell cancer, as scirrhus, or as gelatinous or colloid cancer. Scirrhous cancer of the intestines may resemble in appearance and texture the ordinary medullary cancer, degrees of hardness or of softness depending upon the predominance of the stroma or of the cellular elements in the constitution of the tumor. Rarely, and in a purely clinical sense, cancer of the bowels may exist as a lympho-sarcoma in the small intestine, and then through progression from the glands of the mesentery or elsewhere. Primary intestinal sarcoma has, however, been observed. Similarly, melano-sarcoma has been detected in the intestine as secondary to this form of sarcoma, originating in the skin or in the eye.

Of the forms of carcinoma, cylinder-cell cancer is the most frequent. Carcinoma gelatinosum or colloid cancer is of great relative frequency, but it is altogether probable that here, as elsewhere, this represents a degenerative form of ordinary carcinoma. At all events, it is certain that it may be detected in many cases where the essential changes reveal the ordinary glandular or cylinder-cell variety. These forms of cancer may affect the bowel primarily or secondarily by extension from adjacent organs and textures, or by metastasis. Primary cancer occurs most frequently, metastatic cancer with great rarity. The relative frequency of the different forms of cancer is not definitely known. In the article on carcinoma in the Dictionnaire Encyclopédique des Sciences médicales (xii. pp. 576, 577) cancer of the bowels is said to constitute about 8 per centum of all carcinomatous new growths. Sibley found that primary {869} carcinoma occurred in the alimentary canal (exclusive of the mouth, tongue, and the annexed organs) in 6 per centum of the cases collated by him. Tauchou's compilations of nine thousand fatal cases of carcinoma show that intestinal cancer was present in 4 per centum. These computations include cancer of the rectum. If statistics of cancer of the bowels exclusive of rectal cancer were available, they would show, doubtless, a much smaller proportion.

Any portion of the intestinal tract is liable to be attacked by cancer, though undoubtedly some parts of it with much greater frequency than others. Köhler reported that in thirty-four cases the cancer was situated twenty-two times in the large intestine (the rectum excluded) and twelve times in the small intestine (nine times in the duodenum). It is not unlikely that in the cases of duodenal cancer the new growth extended from the pylorus. At all events, primary cancer is seated with far greater frequency in the large intestine, and, not including the rectum, usually in either the sigmoid flexure or the cæcum. Grisolle declares the large intestine to be four times more often affected with cancer than the small intestine; that the sigmoid flexure is attacked as often as all the rest of the colon taken together; and that the cæcum is still more often affected. Where the intestinal new growth is secondary to carcinoma elsewhere, it is usually so by extension from neighboring parts; thus, the ileum may become implicated by contact with uterine cancer, etc., and cancer of the stomach, liver, kidney, etc. may invade the colon.

Cancer of the intestines usually begins after the middle period of life, and apparently irrespective of sex. Nevertheless, young persons are occasionally affected, and children sometimes develop malignant new growths of the bowels (usually sarcomatous), either primarily, which is rare, or secondarily, by extension from other parts. The influence of heredity seems not to be well established. There can be no doubt that chronic irritation may act as an exciting cause of cancer of the bowels, as it may in cancer of other parts. It has been impossible to recognize any specific influence from especial forms of irritation, and it is not likely that such exist. Indeed, the etiological relations of intestinal cancer remain exceedingly obscure.

SYMPTOMATOLOGY.--Up to a certain period of development cancer of the bowels will give no sign of its presence; indeed, cases have been observed where, death having occurred from other causes, the existence of the malady became apparent only at the necropsy. In all cases the symptoms are, at first, of an indefinite character and very inconstant. Vague abdominal pains are experienced; these gradually tend to become referable to a certain locality and to become associated with irregular action of the bowels. Constipation, alternating with short intervals of diarrhoea, supervenes, and a varying amount of meteorism is developed. These symptoms may be attended by the signs of failing nutrition. The body gradually shows the effects of chronic imperfect assimilation, and becomes emaciated. The complexion slowly assumes the peculiar hue of chloasma cachecticorum. Long before this occurs, however, the cancerous new formation usually becomes perceptible as a more or less distinct abdominal tumor, movable or fixed, as the part affected permits of free movement {870} or is bound down to the neighboring parts either by normal attachments or by adhesions resulting from inflammatory processes or from the extension of the cancerous growth. When the tumor is movable, it is generally situated in the small intestine or transverse colon or sigmoid flexure, the other portions of the intestinal canal being comparatively fixed. It should be mentioned, however, that portions of the intestines normally freely movable may become adherent to contiguous parts, as the transverse colon, with the gall-bladder, liver, stomach, spleen, etc. etc.; the transverse colon and small intestine, drawn down by the weight of the new growth, with the pelvic organs, the bladder, uterus, uterine appendages, etc.; and that, finally, different portions of the bowels may become involved in one mass.

When the duodenum is the portion implicated the tumor may escape observation or may be indistinguishable from cancer of the pylorus. It occasionally happens that no tumor can be discovered until the malady is far advanced whatever part of the bowel is affected. In nearly all cases, however, before very long the tumor will be detected wherever situated, but it will often remain difficult, owing to its situation, to arrive at exact conclusions as to its precise character. Usually, it offers considerable resistance to the touch, but its features may readily be obscured by the fecal accumulation that forms above the constricted portion of the gut and by the gaseous distension of the bowel. This tumor will be slightly painful to pressure, and the patient will refer to it a spontaneous pain, usually of a dull aching, sometimes of a stabbing, character. Percussion yields a sound of muffled resonance, due to the tubular nature of the tumor. Cancerous neoplasms of the bowel, and of the duodenum especially, are apt to be associated with a distinct pulsation caused by the subjacent abdominal aorta. This may readily be distinguished from aneurismal pulsation by the absence of an expansile character, by the disappearance of the impulse that may sometimes be observed when the patient is made to kneel upon all fours, and by the occasional mobility of the cancerous tumor. By extension and by inflammatory infiltration the tumor frequently becomes converted into a conglomerate mass where all determination of locality becomes conjectural. The tumor is, with very rare exceptions, single.

The symptoms that accompany the development of these growths depend mostly upon their position in the alimentary tract. Pain alone seems independent of this, but is at best a most uncertain concomitant. When the duodenum is the part affected by extension from the pylorus, the symptoms are indistinguishable from ordinary pyloric cancer. Even primary cancer of this part may exactly simulate pyloric cancer. The localized pain and tumor, the vomiting after meals, the frequent presence of blood in the vomited matters, the progressive emaciation from starvation, the absence of abdominal distension (a result of the constriction of the gut at its upper extremity), the gastric dilatation,--all combine to make the diagnosis difficult.

Cancer of the duodenum in its descending part may be suspected when signs of hepatic and pancreatic obstructive difficulties point to implication of the ducts, through which are produced jaundice upon the one hand, and evidences of imperfect pancreatic digestion, in the presence of undigested fat in the stools, upon the other. In the lower portions of the {871} intestines the cancer becomes more and more associated with meteorism and fecal accumulations. Constipation becomes steadily more obstinate, but there are occasional fluid evacuations containing blood, pus, and mucus, often stinking abominably. When the tumor is toward the end of the large intestine--in the sigmoid flexure, for example--fluid discharges occur with very great frequency at times; but these are scanty in amount and but slightly fecal in character. In these cases one does not usually observe the compressed, ribbon-like stools that are seen in rectal cancer. These symptoms may precede the appearance of the tumor, when the diagnosis will be less readily made. The constipation will at first be more amenable to the use of purgatives. (It is said to be due more to a loss of contractility of the bowel than to the narrowing of its lumen.) Gradually these will lose their efficacy, and finally complete obstruction of the lumen of the gut is effected; in which event the symptoms of ileus will develop, with cramps and vomiting, finally of a fecal character, and the fatal issue quickly follow. Not unfrequently peritonitis is developed, and may be of a chronic character or may destroy life within a day or two, or the patient may die from exhaustion before the obstruction becomes complete.

It may happen that the integument will become involved in the malignant process, or may become continuous with the tumor by adhesive inflammation. In such cases an opening may be formed by suppuration, or the lancet may secure the passage of feces through an artificial anus, and temporary respite be obtained. Sometimes a sudden disappearance of the symptoms of obstruction--a result due to the softening and breaking down of the cancerous mass, restoring temporarily the integrity of the intestinal tube--may give an unjustifiable hope to the patient; or the same effect may follow the establishment of a communication, by ulceration, between the bowel above the tumor and some portion nearer to the anal orifice. The progress of the new growth soon annuls the benefits thus gained.

Not uncommonly, particles of the cancerous mass may become detached, and, if diligently searched for, may be discovered in the feces. Microscopic examination may then definitely determine the nature of the disease. It has been claimed that colloid cancer may be diagnosticated in this manner even before the appearance of other symptoms. Death may be hastened by the occurrence of metastatic deposits in other and vital organs. Oedema of the lower extremities (of the left extremity in cancer of the sigmoid flexure) will often be observed as a result of the interference of the cancerous mass with the return of blood from the extremities by pressure upon the large veins. The combination of pain, tumor, constipation, tympanitis, progressive wasting, and the cachexia that sooner or later supervenes, stamps eventually most cases with unmistakable characters.

The duration of intestinal cancer may extend from several months to one, rarely two, years, the latter age sometimes being attained by colloid cancer, the most chronic and least malignant form.

MORBID ANATOMY.--By far the most frequently encountered malignant new growth of the bowel is carcinoma, in one or another of its forms. The cylinder-cell epithelioma is probably the most common of {872} these, and, as seen in the intestine, offers many naked-eye points of resemblance with ordinary encephaloid carcinoma. It is soft, filled with a milky juice, and may attain considerable size. The tumors appear as discoid prominences of varying size and number. Later, these may become fungoid and ulceration ensue. The growths early involve the whole intestinal wall, and by their increase tend to obstruct the passage of the intestinal contents. When ulcerated they present a nodular, uneven surface, situated upon a thickened base consisting of the infiltrated coats of the bowel. Villous prolongations (villous cancer; the undestroyed connective-tissue stroma) may project into the lumen of the bowel and give a peculiar tufted appearance to the part implicated. One or more points may be invaded by cancerous growth, and above each will be developed a dilatation of the gut (the result of distension) containing uncertain quantities of fecal matter, upon the removal of which the tumor will appear much smaller than it appeared during life.

Scirrhus usually implicates the gut in its entire circumference, so that a high degree of constriction may result from a small amount of cancerous infiltration. It begins as small nodules or plates upon the mucous membrane. As commonly observed, the lumen of the intestine is narrowed by an annular band of gristly hardness. All the coats of the bowel, with the peritoneum, become involved, and frequently the contiguous parts are included in the cancerous infiltration, forming an undefinable mass through which the contracted channel of the bowel may be traced, though often impervious to any but the smallest articles (a crow-quill, for example). The surface of the gut is generally ulcerated, irregular, and nodular. The walls of the ulcer are irregular and infiltrated. It will sometimes happen that the autopsy reveals permeability of the bowel where total obstruction prevailed during the latter days of life. This may be probably accounted for by the disappearance of the hyperæmia that doubtless existed during life and caused more or less turgidness of the growth. Sometimes the connective-tissue element is less predominant, and gives place to a more or less luxuriant cell-development; in a word, scirrhous carcinoma is replaced by soft or encephaloid cancer. This difference is simply one of degree, but is associated with greater rapidity and extent of growth. Ulceration is extensive, and one may here also often discover the villous, tufted appearance of villous cancer, caused by the fringe-like shreds of stroma entangling cellular elements not yet detached from the mass.

Colloid cancer, or carcinoma gelatinosum, may be associated with either of the above-described forms as a degenerative form, or may, apparently, develop as such from the beginning. It is a very frequent variety of the malady. In 27 cases of intestinal cancer, colloid cancer was present in 5, as reported by Lebert. It is most often observed in the sigmoid flexure and cæcum, as are the other forms of carcinoma. It is composed of a considerable mass extending around the bowel. Ulceration is less often found here than in the other forms, nor is there the same tendency to secondary infiltrations. By the unaided eye an alveolar structure may be detected, and when the mass is extensive a soft, jelly-like consistency is presented, together with "a bright, honey-yellow color." Small deposits of the colloid matter may be seen upon the surface. These have been described as resembling wheals of urticaria or herpetic or eczematous {873} vesicles (Bristowe). The glairy fluid of colloid carcinoma oozes from the cut surface of the tumor, bathes it, and is to be found in the intestine.

These different forms of cancer sooner or later invade neighboring parts, as the peritoneum, mesenteric and retro-peritoneal glands, and adjacent organs. On the other hand, the intestines may become invaded by cancer of the peritoneum and other parts. It has even been observed, reversing the usual order of things, as secondary to cancer of the liver (Wilks and Moxon). Under these conditions the symptoms of intestinal cancer will have been associated with those due to the primary affection. Lympho-sarcoma will rarely be found as an extension from the lymphatic glands and involving the small intestine. Melanotic sarcoma may occur as metastatic from an original melano-sarcomatous tumor of the skin or eyeball.

DIAGNOSIS.--In its earlier stages it is impossible to recognize cancer of the intestines. After its symptoms have become established they may resemble those of several disorders. Cancer of the duodenum cannot be distinguished from that of the pylorus unless evidences of pancreatic or biliary disturbances indicate obstruction to the passage of the bile and pancreatic secretions. Previous to the appearance of a tumor one must often remain in doubt. The alternations of constipation and diarrhoea, the signs of partial obstruction, the localized pain usually present, the gradual wasting, will arouse suspicions of cancer, though chronic inflammatory affections of the bowels may induce symptoms not altogether unlike these. The presence of a tumor will supply the additional evidence necessary for a definite diagnosis. It will be necessary to exclude fecal enlargements of the bowels. The cancerous tumor will be somewhat painful, hard, nodulated. A tumor due to fecal accumulation may closely simulate it, and is, indeed, usually associated with it. By manipulation the fecal mass may be moulded, and even displaced, and by appropriate purgative treatment may be caused to entirely disappear. Foreign bodies, mesenteric tumors, and other abdominal enlargements may offer physical resemblances to intestinal cancer, but their symptomatology is usually so different that doubt may be easily dispelled. Syphilitic gummy infiltration, with resulting stricture, is more apt to occur in the rectum than in other parts of the alimentary tract.

The presence of fragments of the new growths may sometimes be detected in the stools, when microscopic examination will determine their nature. With cylinder-cell epithelioma and glandular cancer this is not common, but with colloid cancer much information may be gained by examining the evacuations. According to Charon and Ledegank, colloid cancer of the intestine may be detected before symptoms develop, by the presence of colloid matter in the feces. In the later stages, however, the gelatinous change of all the histological elements may occasion embarrassment, as at this stage the peculiarities of the cellular structure will have been destroyed.