BENIGN GROWTHS are generally pe dunculated; cancers rarely so; benign growths, unless ulcerated, are bathed in healthy, transparent mucus; cancers dis charge offensive, chocolate-colored mat ter, the odor of the same being almost pathognomonic of malignant disease. Benign tumors are not friable, like ma lignant growths, nor do they bleed as easily. Benign neoplasms spring from a soft, healthy mucous membrane, which glides freely upon the deeper coats of the bowel, while the malignant tumor grows from an indurated lump or patch in the bowel, which seems fixed or rigid. In suspected tumors, in which the diagnosis is at all obscured, a small specimen of the same may be obtained by scraping the tumor either with the finger-nail or a curette, and subjecting the excised portions to a microscopical examination (Andrews, op. cit., pp. 112-13).
- Prognosis.—The duration of the symp toms will prove of value in reaching a conclusion; the onset and progress of benign neoplasms being extremely slow. In malignant disease there is usually a portion of tolerably healthy mucous membrane between the growth and the anus, whereas in the non-malignant stricture this portion of the bowel is generally more or less infiltrated (Harri son Cripps, op. cit., p. 333).
causes of this disease are not known, and even its pathology is subject to dispute. The question of heredity is an open one, and probably if it be a factor it is one of only slight importance. Climate, as noted by the Messrs. Andrews, influences the tendency to cancer. These authorities state that it is clear that in this country cancer prevails most near the sea, and least of all at a distance from it; also, that, at equal distances from the sea, it abounds decidedly more at the North than at the South. The germ theory, as applied to the origin of this disease, has some ardent advocates, but so far success in proving this to be more than a theory has not crowned the efforts of the microscopists.
surgical treatment of this disease will first engage our atten tion because it is to such procedures that we must look to for the most relief. If it were possible to recognize the existence of cancer at its earliest stages and to ob tain consent for its radical removal, the prognosis of such operations would be greatly bettered and the statistics would show, at least, a remarkable prolongation of life. Great relief from its most dis tressing symptoms would also be afforded.
It is frequently a hard matter to de- • cide which of the surgical procedures is ' to be resorted to, the aim being to afford the greatest relief with the incurrence of the minimum risk. The recognized
procedures are four in number: extirpa tion; colostomy, inguinal and lumbar; posterior linear proctotomy; and curet tage.
EXTIRPATION.—The ideal method of treating cancer of the rectum would be by extirpation, as is clone in cases of the same disease when the mammary gland is the site affected; but unfortunately it is not often that the rectal neoplasm is discovered in time to permit the entire removal of the growth and of all gland ular involvement; consequently, it is my belief that the cases in which this op eration is indicated will be confined to a relatively small number of cases.
Kraske, of Freiburg, recommends a radical operation for the excision of the rectum. to 1897 (Sammlung klin. Vort., 183-184, '97) he had operated upon SO cases, 15 of which died. The SO cases divided into two series, the first of which occupies five years, during which writer was perfecting the operation; it com prises 29 cases with 10 deaths, giving a mortality of 34.5 per cent. The second series, extending over the last 7 years, includes 51 cases with only 5 deaths, be ing a mortality of 9.S per cent.
The operation is as follows: The pa tient being placed on his left side, an incision is made starting from the second piece of the sacrum and extending down to the anus, in the middle line. The soft tissues are then carefully raised from the sacrum, the coccyx is excised, and the sacro-sciatic ligaments are severed at the sacrum. The rectum is thus brought into the field of operation. If it is sary to increase the field a portion of the left side of the sacrum opposite the third sacral foramen may be removed. Kraske does not favor sacral section above this level, nor does he recognize the utility of a temporary or osteoplastic resection, which some advocate with a view to pre vent prolapse of the pelvic organs, owing to a presumed weakening of the floor of the pelvis. The resection of the cancer is begun by him with the division of the bowel below the tumor by opening it transversely; sutures are then placed in the upper cut surface for traction poses. The patient is then brought into the lithotomy position, and the tion proceeded with. Sometimes the peritoneum can be peeled off the bowel; but. if necessary, it must be opened, two fingers introduced, the gut pulled clown, and the operation proceeded with.