"In the tuberous form the growth pro jects into the bowel. Its consistence varies, being sometimes hard and firm and in other instances soft and fungoid. One such mass may be present; or there may be several growths of the same char acter, but varying in size. At first the mucous membrane, though firmly adher ent to the tumor, remains intact, but is soon destroyed by ulceration, and a por tion of the growth is then apt to project through the opening thus made. Some times the membrane gives way at several spots, at which nodules or larger portions protrude. Such outgrowths are soft and friable. Sometimes the destructive proc ess is too rapid for the development of fungoid growths; when the surface gives way, the ulceration continues to extend deeply and superficially until the mus cular coat is laid bare. The cancerous , process invades the neighboring tissues and structures,—e.g., bladder, urethra, or vagina,—and openings are made into these parts. The process again may ex tend toward the sacrum and involve the nerves and bones of the pelvis. Occlu sion of the bowel by a fungoid mass is a less frequent result.
"In the annular form the growth be gins as a deposit between the mucous and muscular coats, and extends latterally so as to involve the whole circumference of the bowel, but does not spread upward to any great extent. The subsequent con traction diminishes the calibre of the bowel and causes a marked degree of stricture." Symptoms. — The early symptoms of cancer of the rectum are far from being characteristic. Indeed, it often exists for a considerable period before the patient is cognizant of any trouble. Frequently patients consult a about hoemor rhoids or some minor affection of the rectum or anus, and it is only after a digital examination that the presence of cancer is recognized. Generally, the first sign experienced, in cases of this disease. is a sensation of uneasiness in the lower part of the back and along the inner sides of the thighs, with possibly a simi lar feeling within the rectum. At the end of a day's work this may be sup planted by actual pain, of a dull, heavy character. The next and most usual
symptom is morning diarrhoea. As soon as the patient gets out of bed, or soon thereafter, he is obliged to go to the closet. He may or may not pass any ftecal matter, but does pass a thin sani ous discharge, having a most character istic odor. Later the bowels move sev eral times during the morning and most of the stools consist of this sanious dis charge. The color of the stools is such that most patients ascribe their trouble to piles, and the discharge is attributed to blood from the latter. Constipation may alternate with the attacks of diar rhoea.
Pain is nearly always a very late symp tom of cancer of the bowel; this depends. however, upon the rapidity of the growth of the neoplasm. As soon as the growth invades the anal portion, or neighboring organs or involves the sacral nerves, pain becomes a marked factor. Obstruction of the bowel and the straining efforts at defecation will tend to increase the pain.
The discharge varies in quantity in dif ferent cases and at various stages of the development of the growth. In the early stages the blood is probably brighter in color and is derived from the congested vessels in the neighborhood of the tu mor, but later on the hremorrhage is due to ulceration and erosion, as well as to congestion. In some cases the constitu tional effects arc most marked. In nearly all cases there is loss of flesh and strength. Sometimes the cancerous cachexia is not sufficiently marked as to be very notice able. In the late stages the liver is often enlarged. The lumbar and pelvic glands are usually involved, although this con dition may not be so marked as to be readily distinguishable.
The duration of the symptoms varies in different cases and depends, to some extent, upon the age of the patient and the character of the neoplasm. In the young the disease generally runs its course quite rapidly, and when the growth is soft its effects are more rapid.
Diagnosis.—There are two conditions which are likely to be confounded with malignant disease of the rectum, one being benign growths and the other neo plasms external to the bowel.