Cancer of the rectum : its pathology, diagnosis, and treatment, including a portion of the Jacksonian prize essay for 1876

Preface

The Council of the Koyal College of Surgeons confined the subject for the Jacksonian Prize Essay in 1876 exclusively to the treatment of rectal cancer. Since writing the Essay I have devoted much time to the study of the minute anatomy of malignant rectal disease, and have also had frequent opportunities of increasing my knowledge of the diagnosis and treatment of the disorder. In this work, therefore, the scope of the original Essay has been considerably enlarged.

I take this opportunity of stating how much I am indebted to the kindness of Sir James Paget, Mr Gay, Mr Doran, and other friends for the opportunities they have afforded me of examining various specimens of the disease.

W. HAERISON CRIPPS.

6, Steatpoed Place, W. ; October, 1879.

Chapter I Page

Inteobuction. — Definition of term cancer — Death-rate from cancer — Eelative frequency in men .and women — Hereditary nature of cancer, evidence against — Keturn after removal — Cancer following injury — Method of propagation — Dissemination to distal parts — Cancer caused by local application — Examination of the tumour — Secondary deposits, nature of . .1

CHAPTER II Rectum in Hbaith. — Coats of the rectum, how connected — Thickness of coats — Mucous membrane — Lieherkuhn's follicles — Size and number of cells — Interfollicular tissue — Punction of mucous membrane — Villi — Continuity between lymphoid cells and nuclei of epithelium . . . . • .37

CHAPTER III Pathoiogt. — ^Varieties of malignant disease — Colloid cancer — Adenoid nature of malignant disease in rectum — Resemblance of growth to Lieberkuhn's follicles — Malignant adenoid growth — Lamina form of disease — Ulceration— Formation of tumour — Structure of growth — Position of growth — Epithelial cellsof growth — Formation of fibrous tissue . . . .47

CHAPTER IV Method op Extension. — Extension from the surface — Formation of cavities — Formation of new cells — Forviii

Gontents

PAGE

mation of lymph spaces — Invasion of neighboui-iug structures — Apparent transition from lymplioid to epithelial cells — Differeuce in structure between rapid and chronic growths . . . . .77

CHAPTER V

Diagnosis. — Early symptoms of disease — Pain — Bleeding — Discharge — Diarrhoea — Constipation — Obstruction — Digital examination — Stricture . . .92

CHAPTER VI Diagnosis (continued). — Diseases likely to be mistaken for malignant growths — Villous tumour — Disseminated villous — Polypi — Ulceration of the rectum, simple and syphilitic — Sero-cystic disease .... 118

CHAPTER VII

SuEGiOAi Anatomy op the Rectum. — Relations to neighbouring structures — Recto-vesical pouch iif peritoneum — Blood-vessels, nerves, lymphatics . . . 127

CHAPTER VIII Teeatmbnt. — Palliative treatment — Colotomy for pain,

for complete obstruction — Stricture . . . 133

CHAPTER IX Teeatment by Excision. — History — -Cases suitable for excision — Methods of operating — Ligature — Ecraseur and knife — After treatment .... 143

CHAPTER X

Condition of the Rectum aetee the Opeeation. —

Stricture — Incontinence .... 160

CHAPTER XI Peognosis. — Immediate risk to life — Amount of life to be

gained — Condition of patient .... 164

CHAPTER XII Cases ....

CHAPTER I

There is no reason for supposing that cancer when situated in the rectum differs essentially in its nature from the same disease in other parts of the body. It may be well, therefore, to take a brief glance at the general nature of the disease.

So much ambiguity has arisen, as to the meaning of the word cancer that it may be well to define the sense in which the term is used in this essay. The modern school of pathologists limit the term to express a group of tumours presenting certain definite structures under the microscope. In this group are included scirrhous, medullary, colloid, and epithelial growths, but the various forms of sarcoma are excluded. The older surgeons, on the other hand, conaider tlie expression cancer as synonymous witli tlie term malignant. It therefore incladed all varieties of growth that have a tendency to recur after removalj to infect neighbouring glands^ or to become generally disseminated about the body. When the Council of the College of Surgeons set the subject for the Jacksonian Prize Essay for 1875, on Cancer of the Rectum considered with the possibility of Cure by Extirpation/' it was in the latter sense that the term was used. I shall, therefore, in the subsequent pages, use the word cancer as equivalent to malignant growth.

The death rate from cancer has shown a pretty steady relative increase during the whole period of which we have accurate returns. The following table, compiled from the Registrar- General's Reports, shows the proportion of deaths from this disease, compared with those from other causes, during each of the twenty-six years from 1851 to 1876.

1852 „ 73

1853 „ 72

1854 „ 73

Table.

1861 „ 58

1862 „ 58

1863 „ 62

1864 „ 60

1871 „ 62

1872 „ 48

1873 „ 46

1874 „ 47

1856 64

1857 „ 69

1858 „ 68

1859 „ 64

1866 „ 59

1867 „ 54

1868 „ 53

1869 „ 52

Or if we compare the death rate with the nuraber of persons living it will be found that whereas in the ten years 1851 to 1860 it averaged annually one death from cancer in every 3150 persons living, in the next ten years, 1861 to 1871, the proportion had increased to one in 2570. The mortality from the disease varies widely in the different districts of England. Nor is it only in different parts of the country that this variation is marked, for even in the subdivisions of the metropolitan districts there is a wide divergence in the rate of cancer mortality. Whereas in Marylebone, St George's, Hanover Square, and West London, the rate is 80 in 100,000, it is less than half this in St Luke's, Bethnal Green, and Rotherhithe. In forming these tables deaths amongst women have alone been included.

Cancer is not only more than twice as frequent amongst females as it is with males, but the occupation of men in the London districts often takes them away from their homes for at least half the twenty-four hours, and would thus bring them under different influences from those to which they would be subject at home ; while, on the other hand, women generally pass the greater portion of their day in the same locality.

Modern surgeons differ materially in their views as to the origin of cancer. The widest divergence in opinion lies between those who consider that the origin of the disease is to be sought in purely local causes and those who deem that it is rather to be found in some deep-seated condition of the constitution. Those who consider that the constitution is in fault believe that there is a condition of the body generally, which renders it liable to burst into cancer with some slight accidental irritation, or even without any apparent irritation at all. In fact, they consider that there is a predisposition or liability to the disease, found only in a certain proportion of human beings, and the tumour is looked upon as merely the expressioa of a previous morbid condition of the body in general, analogous to the sudden outbreak of inflammation in the joint of a gouty person, or the development of bony growths about the joints of a rheumatic sufferer. Dr Payne expresses the meaning of constitution, as regards cancer, as a "lesion or change in which the general disposition of the body has a very large share, and the influence of external causes — injury, irritation, and so on, has a comparatively small share." As opposed to these views, those who think that the disease is purely local in its origin contend that the tumour is due to some cause that acts locally on a particular part, and that this is the starting-point of the cancer, there being no previous disposition of the body to the disease, but that it only becomes secondarily affected from this original centre.

Many facts and arguments have been brought forward to support either view of the origin of the disease. In favour of the constitutional origin are, firstly, the hereditary nature of cancer ; secondly, its almost inevitable return after removal ; thirdly, its production in certain persons as the result of an injury.

The transmission of cancer by inheritance, or the particular condition of body liable to be attacked by the disease, has been taught from the earliest times, and is, perhaps, the strongest argument in favour of the constitutional view. Indeed, it cannot be regarded as other than certain proof that a tendency, at least, to the disease has been directly transmitted. Sir James Paget, a high authority on the subject, goes so far as to state that " he is disposed to hold that it is not possible to conceive the origin of cancer, or any disease of the kind, except by inheritance." Instead of elaborating ingenious theories, such as the localists employ to get over the difficulties of inheritance, or the still more complicated excuses which the constitutionalists find for cancer skipping a generation or two, it may be well carefully to weigh the facts upon which the doctrine of inheritance is founded. In the 14th vol. of ' St Bart. Hosp. Eep.' I published a short paper on this subject, from which I give the following extract :

" The hereditary nature of cancer is based upon evidence derived from the following sources :

" 1st. That it is a matter of common notoriety that cancer runs in certain families.

" 2nd. Evidence founded upon certain statiatical facts.

" Now, in dealing with the former statement, such evidence is wholly inadmissible from a scientific point of view without the positive -facts upon which it is based. Theories universally held are not uncommonly evidence of a widespread ignorance.

" From time to time isolated instances may occur of an amount of cancer in a particular family in excess of the average to be expected. Such, for instancOj as the case narrated by Sir James Paget (vol. xxv, p. 318, ' Pathological Society's Transactions in which a lady died of cancer, two of her daughters died of cancer, and eight of her grandchildren ; however, the number of her children and grandchildren who did not die of cancer is not mentioned.

" The rareness of such an instance is proved by finding that, out of nearly 300 cases of cancer at St Bartholomew's Hospital, nothing in the least approaching this history is to be found.

" The evidence derived from statistics will now be examined.

In an article by Mr Baker, in the 2nd vol. of the ' Hospital Keports,' will be found a table of cases from the practice of Sir James Paget. Mr Baker makes this statement, that 22"4 per cent, of the cancerous patients were aware of one or more relatives with the same disease. He then gives a table of 103 cases in which one or more relatives were affected. These 103 cases representing only 22 "4 of the total number of cases examined, the whoh number of cases investigated must have beei! 460. In these 103 cases amongst the relatives are included aunts, uncles, cousins, first, second, and third, great-aunts, and a greatuncle. But since it is impossible to conceive how a man can inherit cancer from his uncles, aunts, or cousins, the necessity for excluding these is obvious. Further than this, the impossibility of knowing the number of these distant relatives, in order to form a table for comparison between a cancerous and a non-cancerous family, renders them useless for our present purpose.

"This objection cannot apply to a man's parents or grandparents ; two of the former and four of the latter must be the invariable amounts Now, it is not within the range of ordinary observation that an individual, especially of the hospital class, could even with approximate accuracy assign the cause of death in his four grandparents. The cause of death in the parents is, however, commonly known, especially if the deaths were from cancer. On these grounds, therefore, will be considered the relative frequency with which malignant disease is found in the direct oifspring of a cancerous or non-cancerous parent.

"Eeferring to the 460 patients, these must have had 920 parents, unless brothers and sisters belonged to the same family. This was so in four instance ; the number of parents will thus be reduced to 916. Amongst these 916 parents cancer occurred 30 times in the mother, 7 times in the father, or a total of 37 times.

" This gives one parent in every 24-8 who died from cancer. But a person has two parents, therefore the chance will be only 12-4 that one of them died of the disease.

" Thus far it is clear from these statistics that one out of every 12^ cancerous patients whom we question will be found to have lost a parent from the disease.

" Two objections to these facts might well be raised :

" 1st. That it is assumed that all the parents of the cancerous patients were dead ; but this would not be the case, and that those still living might eventually die of cancer, thus swelling the cancer mortality.

" 2nd. That they might have died of an unknown cancer.

" Now, the first objection must readily be admitted, but taking into consideration that in a vast majority of instances cancer is a disease of advanced middle life, it would be in only a small number of instances tbat the parents, if living, would eventually die of the disease.

" As a proof of this, it will be found that in the whole series of Sir James Paget^s cases only three instances are recorded in which a parent has succumbed to cancer subsequent to an offspring dying of the same disease ; this amounts to less than 1 per cent, in the whole number'of cases. The objection that the disease might have been an unknown cause of death would apply equally to the Eegistrar-Greneral's returns, to be presently alluded to.

" The figures given in Mr Baker's table of Sir James Paget's cases will now be compared with those derived from the Eegister of St. Bartholomew's Hospital. From June, 1869 (the first commencement of registration), till October, 1878, 280 cases of cancer were under treatment in the female surgical wards. Out of these 280 cases in 111 of them no family history of any kind is recorded ; in the remaining 169 cases a special record is made as to the family history. In these 169 cases no cancer was known in the parents in 156 instances ; in 11 cases either the father or mother had cancer ; in 2 cases it was doubtful whether or not one of the parents had the disease^ one of these being so doubtful that I have thought fit to exclude it. There will remain, then, 12 cases amongst 336 parents, or 1 case in 28, or a chance of 14 to 1 against a cancerous patient having a cancerous parent.

"Now, as Mr. Baker very properly observes, in speaking of Sir James Paget^s cases, these statistics in themselves do not prove in any way the inheritance of cancer, and this question can only be finally answered by discovering the proportion of cancerous relatives belonging to those not cancerous

" ^Vhat we have to do is to compare the death rate from cancer in the parents of cancerous patients with the death rate from cancer amongst adults generally. Fortunately in the Registrar- General's returns we have a means of making this comparison.

"It would not be right in this calculation simply to take the whole number of deaths in the community and find out how many of these deaths were due to cancer, for the parents of cancerous patients must certainly have been adults at the time of their deaths.

" The total number of marriages below the age of 20 only amounts to 8 per cent., and the proportion of these who both become parents and die below the age of 20 is so small a percentage that it can be fairly ignored. Thus, then, we will compare the death rate from cancer in the parents of cancer patients with the death rate from the same disease in all persons in the kingdom dying above the age of 20 years.

"In the ten years 1861 to 1870 in England and Wales —

" 1,185,189 men died above the age of 20 years. " 1,194,433 women died above the age of 20 years.

" 24,845 men died of cancer.

" 56,854 women died of cancer.

" The addition of these figures gives 81,699 deaths from cancer out of 2,379,622, or 1 death in every 29*1 from cancer.

" By comparing these figures with the figures given in the previous page, the following result is arrived at :

" Amongst the parents of cancerous patients the death rate from cancer is —

" 1. According to Sir James Paget, 1 in 24'8. " 2. According to St. Bartholomew's Eegister, 1 in 28. "3. Amongst the whole community over 20 years of age, 1 in 29.

" The relative frequency of cancer in these two sets of cases differs so slightly that this difference may well be looked upon as accidentalj in wliicli case, the figures given in the paper bear proof tliat cancer in the parent in no way increases the liability of the offspring to suffer from the same disease."

Statistics collected by other observers might lead to different conclusions. Every endeavour^ however^ has been made to make the foregoing figures accurate, and until more evidence is adduced than is now accessible to prove the inheritance of cancer, I do not feel justified in admitting the doctrine as evidence of the constitutional origin of the disease.

Tlie return after removal. — This, not merely in situ, but disseminated about the body, has been regarded as evidence of the part played by the constitution in the production of the disease. In speaking of this argument, Sir James Paget states: "I would hold that the constitutional element in the origin of cancer is strongly marked in the constancy and in the method of its recurrence after operations — recurrence after complete excision. . . . You may cut out little cancerous tubercles here and there from some old person three, four, five, or six times over, but that is a different disease. You cannot find an instance of rapidly-growing, soft-textured, vascular cancer of any form which can be removed three, four, six, eight, ten, or twenty times without recurrence, not in the place of growth alone, but in distant organs ; and I believe it is vain to attempt to explain this difference of the recurrence in distant and dissimilar parts which we find in recurrent tumours, or, occasionally, in the more ordinary kinds, upon any facts of difference of physical constitution. I observe it is referred to the mobility of cells, to their readiness to travel, that now and then these tumours pass from one part to the other. Now, really there are cancers that multiply themselves in dissimilar parts whose physical condition looks as unfit for travelling as any that could be named. If I could name any kind of cancer which propagates itself more widely and readily than another, it would be osteoid, a mass as hard as any mass of fibrous tissue you ever found in the uterus. I know no fibrous tumour which is so hard as the fibrous mass, to say nothing of the bony structure, of an osteoid cancer, yet it propagates itself speedily and everywhere. Ordinary scirrhous cancer of the breast is at least as hard as an ordinary fibrous tumour ; but the one does what the other does not— propagate itself. The recurrent fibroid, or recurrent cartilaginous growths, are just as soft, and are composed of cells and free nuclei as little held together as in any of the soft forms of cancer. They do not, except in rare cases, propagate themselves. Cancers do not fail, except in rare cases, to propagate themselves, so that I must maintain that, whichever way we look at them, the facts of the method of propagation to distant and dissimilar parts are so strong, and so characteristic on the side of cancers, that we must assume an essential difference between them and any other tumours that we can name.'"

But yet this argument, when considered, amounts to no more than stating that there is a marked difference in the physical character of cancer and that of the innocent tumours, a fact readily admitted. If, however, it can be shown, as I will endeavour to do on a subsequent page, that all the particles of the disease found disseminated about the body are the results of the primary tumour, and started from it, then, instead of the dissemination being an argument in favour of the part played by the constitution, it appears to point in an exactly opposite direction.

Now, as regards the outbreak of cancer that is alleged rapidly to follow an injury, as a matter of fact it is impossible to deny that the actual starting-point of cancerous growth results from an injury in a certain uumber of cases, and this, too, after injuries of a peculiar nature and in certain parts. The form of injury that apparently starts the disease is not an incised, lacerated, or punctured wound, but rather that form of injury known as contusion, and this, too, often of a trivial nature. Again, the parts in which a malignant tumour follows a blow is generally glandular tissue. A remarkable instance of this formation of malignant disease after an injury is, at the present time, under the care of Mr Thomas Smith at St Bartholomew's Hospital,* the details of which will be found in the footnote.

* E. R— , police constable, in June, 1878, while arresting a prisoner, received a kick on the left breast; it was not very severe but caused him some pain at the time, and did not prevent bis being on duty the following day. Twenty-four hours after the injury there was a bruise the size of a florin around the nipple. The marks of this remained for some weeks and then disappeared. Ten weeks afterwards he noticed for the first time some hardness round the nipple, about the size of a small marble. He treated this by fomentations and poultices, but it continued steadily to increase. At the present time, rather more than a year after first noticing the growth, there is a large projecting tumour, the size of a fcetal head; the skin

Now^ in this case the constitutionalists would see evidence of a constitutional tendency excited to activity from tlie injury, for they would say, and probably with truth, that ninety-nine such blows might be struck on as many individuals without producing a similar result, and from this they would argue that there must be a second factor besides the blow to produce such an exceptional phenomenon, and in this factor they recognise a peculiar disposition in the constitution. JSTow, if such an hypothesis be correct, it would seem that any blow struck on a patient with such a diathesis should be followed by tumour formation ; but yet this is not the case, for wounds or contusions of innumerable kinds have, from time to time, occurred to persons who are actually suffering from cancer, yet, save in the rarest instance, no cancerous growth has resulted. The late Mr Morgan narrates an interesting case which admirably illustrates this fact.*

over it is dasky ia colour and firmly adherent, while in the axilla are two large glands the size of walnuts. He is a strong burly man, no family history of cancer, and has got rather stouter than thinner during the last six months, when he has been off duty.

* A man was brought into the hospital with a compound fracture of the radius, which had occurred four or five days previously. Tlie whole arm was enormously swollen and in a

I I ^ 2

Now, I will readily admit that, seeing the exceptional nature of the police constable's case narrated, there must have been some condition in addition to the mere blow to produce so untoward a result, but what I do deny is, that it is necessary to assume that the additional fector should lie in the patient's constitution at large, rather than in the exact character of the injury inflicted or in the particular condition of the tissue struck.

condition of what may be called putrescent cellulitis. There was putrid pus and serum distending the cellular tissue up to the middle of the arm. The general appearance of the man, notwithstanding this, was regularly healthy. His pulse was 84, he had a clean tongue, and ate and slept well. I contented myself by making incisions, expecting that amputation might soon be necessary ; by-and-bye the carpal bones and the head of the radius became carious, many of the former were removed, the head of the ulna exfoliated. There was copious suppuration, at first foul but afterwards becoming healthy. During all this time, a period of a couple of months, he retained his health, eating, drinking, and sleeping well, with a good colour and slow pulse. I determined to let nature have her course. All at once he was seized with peritonitis. I feared it was pysemic peritonitis and that I had carried the experiment too far. He died and it was found that the peritonitis was due to a portion of the gut having got entangled in a band, the result of a peritonitis which he had told us he had previously suffered from. But in addition to this there was found in the pelvis and lower part of the abdomen a mass of coUoid cancer, while the omentum and intestines were throughout studded with nodules of the disease of various sizes.

Having mentioned some of the chief arguments used by the constitutionalists to support this view of the origin of the disease, it will be well to glance at those features in the history of cancer, which point most strongly to its having a local origin, the constitution only becoming secondarily tainted. Now, first amongst these we have the evidence of the tumour itself, a single spot being alone affected, the rest of the body being in perfect health. In fact, the first indication of the disease being its local manifestation. As an instance, I will take a case*

* A woman, aged 45, had enjoyed thoroughly good health since she was a child. A few months ago she began to feel sUght discomfort in the right breast. This came on so gradually that she could fix no exact date for its commencement. A week ago she noticed for the first time a hardness iu part of the right breast. She is still in perfect health and has no pain to speak of. On examination a hard nodule is felt deep in the breast, but no perceptible glandular enlargement. An operation was advised but declined. She again applied to the hospital four months later; her condition was then much altered, the tumour was larger and very painful, and in the aiiik was a gland as large as a pigeon's egg; she had lost appetite and her nights were often sleepless. She had quitd lost hsr good looks and completion, her face being thin and careworn; she was rery considerably thinner. Being very aniioas for an operation the breast was completely removed, together with the axillary gland; the wound healed rapidly! She left the hospital in good spirits, and during the next few months she regained her appetite and once more looked fairly whicli was under my care at the Royal Free Hospital as being fairly representative of what is commonly observed.

Now when the patient was first seen her health was good, but anxiety of mind, sleepless nights, and pain, soon told their tale, and accounted for the so-called cachexia. After the removal of the local disease she regained to a great extent her former health, only to be lost when the disease returned. Such a histoi'y is common in cancer, all the constitutional symptoms being consecutive to the tumour.

Secondly, the manner in which cancer spreads and propagates itself. There are four methods by which the disease extends. Three of these methods of extension are as clearly recognised, and as universally allowed as any fact in pathology, viz., growth from its periphery, extension by the lymphatics, and dissemination in the course of the blood-stream. The fourth method is by auto-inoculation, but notwithstanding the utmost importance that should be attached to this method of extension, it is practically ignored by the majority of authors on the

healthy ; unfortunately six months after the operation the disease returned in situ, she became rapidly cachectic, and, I believe, died 8 months later.

subject, althougli it has not escaped tlie observation of sucli accurate patliologists as Dr Moxon, Dr Goodhart, and the late Mr Morgan. Almost every museum affords specimens of malignant ulceration of the stomach with patches of cancer scattered here and there along the small intestines or colon. The appearance of these specimens combined with their clinical history leaves little doubt but that these deposits are secondary to the gastric disease. In the Middlesex Museum is a cancerous ulcer in the stomach of a boy who had previously suffered from the same disease in the mouth. In the Pathological Society's Transactions it will be found recorded, and specimens have been exhibited showing how the uterus has become inoculated with cancer through the Fallopian tubes from a diseased ovary, how the lungs and bronchi have become infected from a primary cancer of the larynx, and even the skin of the abdomen become cancerous from contact with a pendulous breast already diseased.