Pathologically these polypi are originally of myxomatous or adenomatous type. They may bleed easily and may be passed with stool. In their multiple and smaller expressions they give rise rather to rectal uneasiness and tenesmus than to more distinct symptoms. On the other hand an isolated tumor, so pedunculated as to become gradually stretched out, may attain considerable size and give rise to all the sensations of a foreign body in the rectum, with constant tenesmus and desire to expel it, while it may even present at the anus or bleed freely.
Only exceptionally will these tumors be recognized previous to examination, which, however, should easily disclose their characteristics. Isolated polypi should be removed, either by being twisted off or by excision and ligature of their bases. General polypoid degeneration may be treated with the curette or with the actual cautery. In all these instances surgical intervention in some form will be required.
Other benign tumors in the rectum are mainly of the adenomatous type. Owing to their location it is rare that they are seen early by one competent to judge of them. In consequence the surgeon sees them usually as more or less ulcerated, sometimes extensive growths, perhaps bleeding freely, and much changed by maceration and by compression from their original condition.
In such cases it becomes a question of importance to distinguish between the benign and the cancerous growths. This is not always easily done, especially when they are high up and ulcerated. The matter is usually decided by the presence or absence of actual infiltration around the base of the growth, and perhaps the involvement of lymph nodes. A movable tumor with an infiltrated base is usually clinically benign, nevertheless it should be radically removed. It is in many of these instances that one may see expressions of transformation of adenoma into carcinoma.
Cancer of the Rectum.
—This will be considered here rather from its clinical side; hence what is said refers alike to sarcoma and carcinoma, the latter being far more common. Carcinoma of the rectum may assume the type either of epithelioma, as when it begins low and spreads upward, or of adenocarcinoma, when it arises from that portion of the tube not lined with squamous epithelium.
It usually begins insidiously, and for a considerable length of time furnishes scarcely any recognizable symptom. The first indications noticed by the patient are usually more or less frequency of stool, with tenesmus, and the passage of mucus, perhaps stained with blood, rather than of fecal matter. By the time those conditions are noticed there will usually be more or less mechanical difficulty of defecation, due to the presence of the tumor and obstruction of the rectal tube. Pain may be a long-deferred feature, and local soreness may be absent until late in the case or until its terminal stage, when the growth is above the peculiarly sensitive part of the rectum, i. e., when it does not approach to within 1¹⁄₂ inches of the sphincter. As time goes on there is more and more suffering in the rectum, with backache, referred pain, while the tenesmus and other local conditions cause increasing distress. It often happens that it is not until this period is reached that the patient consults a physician, and then he usually goes with the statement that he is suffering from piles.
Fig. 594
Epithelioma of anus and rectum. (Grant.)