CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 5)

the pelvis will not infrequently press upon the rectum so as to obstruct its calibre. An abscess in the ischio-rectal fossa may be accompanied by an amount of inflammatory deposit around the rectum sufficient to obstruct it; and a pelvic inflammation in women may be accompanied by an exu- dation which in the form of bands across the bowel shall partially close it, and at the same time lead to compensatory muscular hypertrophy of the rectal wall. Medical literature is full of cases of this nature, and here it is only necessary to refer to them as a not infrequent cause of obstruc- tion both of the rectum and of other parts of the canal. Much has been written in times past upon the question of spasmodic stricture of the rectum, but at present the condition is looked upon by the best authorities with great doubt, if not with absolute unbelief. Spasmodic contraction or stricture of the external sphincter is not an unusual condition, and cases of it from my own practice and that of 182 DIBBASES OF THE BEOTUM AND ANUS. others will be reported further on; but spasmodic stricture of the canal aboYC this point has always been a matter of belief and assertion rather than of demonstration. AUingham upholds its existence in connection with organic stric- ture, as a complication of the latter, and gives the following case as proof. He says: ''There are, no doubt, many cases of stricture in which there is yery little deposit and much spasm; and there are, on the other hand, cases where much obstruction exists, but very little spasm. A patient under my care at St. Mark's had a stricture so tight that I could not make the point of my little finger enter it; on putting her under the full influence of chloroform, I could get two fingers through without difficulty." This case, if it be admitted, as it generally will be on so good author- ity, actually proves more than has ever been proved before with regard to this question, and is about the only one which really proves anything. I have already referred to the difficulty which often exists in passing a rectal bougie from the natural conformation of the parts. It is upon this difficulty that nearly all the arguments for and the supposed cases of spasmodic stricture rest. When the bougie cannot be passed, a spasmodic stricture is supposed to be the Q^use. When, after numerous trials, by a lucky manipulation an entrance is effected, the spasm has been over- come. To this may be reduced nearly all the reported cases of this affec- tion which from time to time have appeared in the writings of those who have devoted attention to the subject. Molliere,* with his usual happy style, has gone very nearly to the bot- tom of this question. He says that at a not very remote period there fiourished by the side of Ashton, Curling, and the surgeons of St. Mark's Hospital certain specialists as expert in finding strictures in the rectum, as are our laryngologists in discovering polypi in the larynx. These estimable practitioners gave themselves up to the daily exercise of dilatation by bougies, and to facilitate the practice, one of them had invented a pair of pants of a special pattern, dressed in which novel livery his patients came daily to have a sound introduced into the anus. Another anecdote is repeated by several authors which illustrates the ease with which patients may deceive themselves or be deceived by others in this matter. A lady went to consult a rectologist for some reason or other which is not stated, and a sound was introduced into her anus. Her husband learning this, rushed to the house of the scoundrel in a violent rage and armed with a whip. Half an hour later he returned disconsolate. He had found out that, like his wife, he had a stricture of the rectum, and, like her, he had submitted to catheterization. This whole question of spasmodic stricture has been very ably dis- ^ Log. cit., p. 820. NON-MALIGNANT BTBICrUBE OF THE SEOTUM. 183 cussed by Van Buren,* and if the reader wishes to follow it further, he oan scarcely do better than to consult that article. Uncomplicated spas- modic stricture of the rectum is a thing whose existence is not admitted by the best authorities, and which will seldom be found by a skilful ex- aminer. It is perhaps too much to say that it never exists, but a well- marked case of it within easy reach of the finger, which could be plainly detected by an ordinary examination, and which disappeared under chloroform, is what those who do not believe in its existence are calmly waiting to see. The changes in the wall of the rectum which may cause stricture, in- dependent of malignant disease which will be considered later, may be divided into the two general classes of venereal and non -venereal, and each of these may be again divided into the cicatricial an4 fibrous. Venereal Stricture. — In the chapter on ulceration stricture has been frequently referred to as a not infrequent consequence of that process, and the various forms of ulceration which by subsequent cicatrization were capable of producing this result have been mentioned. In a general way it may be said that any ulcer which destroys even the thickness of the mucous membrane to any extent will, when healed, leave a cicatrix, and if such a cicatrix be at all extensive it will by its contraction cause subsequent diminution in the rectal calibre. It has been shown that many of the more severe forms of rectal ulcera- tion are of venereal origin. The venereal sores capable of producing a stricture are the chancroid, and the later syphilitic ulcers. We shall leave out of consideration the true chancre, and the mucous patch, for the reason that their influence in the causation of stricture is still rather a matter of surmise than of proof, and the same thing may be said re- .garding gonorrhoea of the rectum. For a description of these ulcerative venereal processes the reader may again refer to the chapter on ulceration; but there is a class of vene- real strictures which are syphilitic, but are not primarily ulcerative and therefore not cicatrical. In this class are to be placed the gummata, the ano-rectal syphiloma which differs from gummy deposit rather clinically than microscopically, both of which have already been described; and a third late manifestation of constitutional syphilis, which is an inflamma- tion of the rectal wall. This inflammatory change may involve a large portion of the rectum. It begins in the muscular fibre, the interstitial tissue of which becomes filled with round cells which ultimately form a connective tissue, and this connective tissue by its hardening and con- solidation finally causes the complete destruction of the muscular element. This is not to be confounded with the ano-rectal syphiloma in which * On Phantom StrictuFe and Other Obscure Forms of Rectal Disease. Amer. Joum. of the Med. Sci., Oct., 1879. 184 HISEA.BE8 OF THB RECTUM AND AKUB. there is an actual depoBit of large maases of new material in the rectal wall — maases which it may be very difSouIt to distinguish from cancer. In these varions ways venereal disease and especially syphilis may re- sult in rectal stricture, and this accounts for the fact that in about fifty per cent of all caaea of stricture there is a syphilitic history. Non-venereal Rectal Stricture. — The non-venereal strictures may be classified as congenital, dysenteric, and traamatic. The congenital narrowing of the rectum which is sometimes seen has been already described in speaking of the malformations of this part. There is also another form of obstruction of the rectal calibre which is supposed to be due to an hypertrophy of the folds of mucous membrane which are normally present in every one. Fid, 48.— Longltudliial secCloD of stricture at the reotum at the plica recti inferior <Kohl- r&usch). a. Uucoiu membrane, b. Circular muscular layer eatering Into the (old o( the stricture. C OeUular Hssue. tl, Loo^tudlnal muscular layer psaaing oTor the stricture. Quain,' under the head of impaction of faeces, describes the case of a man, aged forty years, who died with a large accumulation which was evi- dently due to the presence of two crescent-shaped shelves of mucous mem- brane projecting into the rectum, one attached opposite the prostate and the other about four inches higher. Each of these was more than an inch in breadth, and into each the circular muscular fibres fully entered, while even the longitudinal layer dipped slightly inward at their bases. Kohl- rausch also describes an analogous case, in which he made an autopsy on a criminal who had been executed. (Fig. 48.) He found an enormousdila- of the Rectum, London, Ig54, p. 378. NON-MALIGNANT BTRIOTUBB OF THE KEOTUM. 185 tation of the rectum above the spot at which he locates the plica transver- salis. At that point he discovered an undoubted stricture which, from its hardness and extent, he at first considered cancerous. It presented, however, nearly the same anatomical condition as the one just described; the mucous membrane was sound and formed a considerable duplicature; the circular muscular fibre entered into this duplicature and formed a hard, hypertrophied, muscular ring several lines in thickness. The longitudi- nal fibres passed directly over the affected spot in this case, however, and were not unusually thick or firm, and the space left between the outer and inner muscular layers by the bending inward of the latter was filled with connective tissue. A stricture was in this way formed without degeneration of the mucous membrane — a condition, however, which led to no less serious results. Such a state furnishes in itsel4the ground for constant aggravation, for the longitudinal fibres passing entirely over the fold must, by each contraction and by the necessary increase in their normal function, augment the substance of the fold more and more, and thus decrease the lumen of the gut. NSlaton, indeed, has written that valvular retractions of the rectum are most often only an hypertrophy of his superior sphincter, and that the projection formed by it into the cavity of the intestine is the point at which foreign bodies are most frequently arrested, as well as that at which invaginations in young children gener- ally begin; and in all these points he is borne out by Velpeau,' Sappey* says " at the level of this band most of the organic contractions of the rectum are situated; its study, therefore, offers no less interest in a patho- logical than in a physiological stand-point. '^ This idea of the pathological relations of the mucous folds and muscular bands in the causation of organic strictures may be traced through the works of Arnold, Tanchou, Hyrtl, and Houston; and has its foundation in the fact that, as these folds are the most subject to injuries, so they may be the most frequent starting- point of those contractions of the rectum which are due to injuries, espe- cially those from foreign bodies introduced j^er anum or swallowed, and from masses of hardened fasces, intestinal concretions, etc. Dysenteric stricture and ulceration have also been already described. Stricture due to this cause is, perhaps, more often multiple than when due to any other. The last cause to be enumerated is the simple traumatism which may result in stricture, either by causing ulceration and cicatrization or by exciting a chronic infiammation in the submucous connective tissue. Amongst these traumatisms may be enumerated operations upon hsBmor- rhoids, applications of strong acids, the performance of some surgical operations, foreign bodies, kicks and falls, and the injury produced by the head of the child at birth. * Velpeau, Anat. Chir., 8d ed., 1837, p. xxxix. 'Anat. Descript., t. iv., p. 222. 186 DI8BASB8 OF THE BBCTUM AND AXUS. Pathological Anatomy, — In studying the pathological anatomy of stricture, there are several points to be obseryed, for changes will be found not only at the stricture itself, but both above and below it, and in the surrounding parts. From what has been said already, it will be inferred that a stricture which is not the direct result of a deposit of new material in the rectal wall will be composed either of cicatrical tissue, such as is found in other parts of the body, or else of connective tissue which is firm and dense, and creaks under the knife on section. All the connective tissue in the rec- tum at the diseased point, whether submucous, subperitoneal, or intermus- cular, will be found to have increased in quantity; and this accounts for the increased thickness of the rectal wall. The mucous membrane at the seat of stricture will generally be found destroyed, and replaced by .granulation tissue on this fibrous base, which bleeds easily when scraped. Above the constriction a process occurs which will be found to be almost constant. This begins by a dilatation of the bowel and an hyper- trophy of the muscular layer, with, at first, a thickening of the mucous membrane. Later, the mucous membrane, due, probably, to the irrita- tion of retained fsBces, will show all the stages of ulceration, from simple 'Congestion in some points to a complete destruction in others, and an exposure of the muscular tissue beneath. This ulcerative process may extend for several inches up the bowel. The wall of the bowel above the stricture may be as thin as paper in spots, and at such points perfora- tion is apt to take place. In a case reported by Goodhart,^ the changes of which we are speaking had gone on to actual gangrene, extending in spots along the transverse and descending colon, and were undoubtedly due to the intensity of the inflammatory action caused by the retained irritant matters, ^he bowel is also generally distended with gas and fsBces, and the latter ar^ more often fluid than solid, though fsecal tumors, with their well-known characteristics, will sometimes be met. The dilatation above the stricture may reach an enormous size, and may ultimately result in a cul-de-sac or pouch which will fill a large por- tion of the abdomen, and dip down below the point of constriction, and an ulceration in this pouch may result in its perforation and the estab- lishment of a fistulous outlet for the fsBces. Such an opening may be into the rectum, either above or below the stricture, or into the ischio- rectal fossa, with the necessary result of abscess. An opening may also be made into the bladder in either sex,^and in females, into any part of the genital tract. As showing what efforts nature is capable of making to overcome the occlusion caused by stricture, the following account of the post-mortem appearances found in the body of Talma, the tragedian, is of great in- terest. The whole history of the case may be found in Quain.* 1 Med. Times and Gaz., Feb. 28th, 1880. « Op. cit., p. 190. NOK-MAUOKANT. STRIOTUBE OF THE BBOTUM. 187 In the examination of the body the intestines were all found largely distended with air and faecal matter. . . . The pelvis was filled with an enormous sac — the upper part of the rectum largely dilated. When the sac was raised a circular narrowing of the gut was discovered. This was the stricture. It was at the distance of six inches from the anus, and proved, upon close examination, to be wholly impervious. It was, in fact, a solid fibrous cord, but on the surface irregular, and having the appearance of a purse, drawn tightly and puckered, with the strings tied around it. The great dilatation of the bowel at its lower end, dipped down bel6w the level of the stricture in the form of a dependent sac, in which was an opening about an inch in diameter, and from. this opening issued a fluid, the same as that diffused through the abdomen. The rec- tum below the stricture was no more than the size of a child's intestine, and upon it, close to the stricture, was an ulcerated surface with a nar- row opening, to which the edges of the aperture above the stricture had been adherent. A new commuuication, but an imperfect one, had thus been established between the two parts of the gut — severed one from the .other by the stricture. But the connection had given way, doubtless in consequence of the violence of the expulsive efforts, and thus the con- tents of the bowel had escaped a short time before death. The cellular tissue in the ischio-r^ctal fossae around a stricture may also become hard and lardacous, as a result of chronic inflammation ; and this change may extend to some distance from the original starting-point along the sacrum, as high as the promontory, and into the subperitoneal tissue of the iliac fossae. Abscess is always liable to occur in the neighborhood of the stricture, probably from lowered vitality in the parts, and this accounts for the rel- ative frequency of fistulae in this disease. These may be both numerous and extensive, and may make communications between the rectum and any of the adjacent organs. For this reason a fistula shoiQd always lead the surgeon to think of stricture and to examine for it. AUingham has also called attention to the frequent existence of a low form of peritonitis in connection with stricture, an inflammation marked by tympanites, vomiting, and pain, especially on walking or moving, and attended by thickening of the peritoneum and old and recent adhesions. Below the stricture the rectum may sometimes be found unchanged from its normal condition, but it will generally be ulcerated as it is above, or pise there will be haemorrhoidal tumors, excoriations, and vegetations and condylomatous tags of larger or smaller size. These condylomatous growths are the result simply of irritation of the discharge