5 Charon and Ledegank, Journ. de Med.-Chir. et de Pharm., v. lxviii., 1879, p. 493.
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 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 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,6 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.
6 Journ. de Med.-Chir. et de Pharm., lxviii., 1879.
PROGNOSIS.—Intestinal cancer always proves fatal. Death may result from the debility resulting from the cancerous cachexia or from intestinal occlusion or from peritonitis. The duration of the malady is usually not long. It runs its course in from several months to one, rarely to two, years.