CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 6)

from the pro- cess above. Most strictures are located in the lower part of the rectum, and hence their presence is easily detected in the majority of cases. They are far more frequent in females than in males, because many of the causes which produce them operate chiefly in females. Age has little influence upon 188 DISEASES OF THE BEGTUM AND ANUS. their frequency after the period of adult life. A stricture may or may not involve the whole circumference of the bowel; and the contraction may be so slight as not to be apparent till the bowel is distended with the speculum, when a falciform band may spring oub from one side. In more extensive disease^ there is still usually a passage for the fsBces, but this may be very slight. The most extensive disease will be found to be due generally either to syphilitic deposit, syphilitic sclerosis, or dysen- tery; and in such cases the calibre of the bowel may be lessened for a space of several inches. Symptoms, — Where stricture is the result of ulceration, the signs of ulceration will at first mask those of the stricture, and the patient will complain of pain, discharge from the anus, excoriations, and warty growths, together with the failure of the general health, gastric and in- testinal disturbance, and wandering pains. The one sign of a stricture is the obstruction, and this may show itself in several ways, generally at first by alternate attacks of constipa- tion and diarrhoea. The constipation is mechanical, and is due to the accumulation of fsBces above the constriction. The diarrhoea is secondary, to the accumulation, which, in time, begins to act as a foreign body, set- ting up a catarrhal inflammation, as a result of which sufficient fluid is poured into the bowel to soften the hardened mass, and large quantities are discharged, only to be followed by a fresh accumulation. It has often been asserted that a well-marked lessening of the rectal calibre must, in the nature of things, produce a change in the shape of the fsBces, but this is not quite true. The flattened, tape-like stool is a sign of value when present, and should always lead to careful exploration, but it may not be present even in the worst cases of stricture, and it may exist without stricture; in the latter case generally being due to an irreg- ular spasmodic action of the sphincters, or to pressure from without the bowel. This point, to which attention was called by White * as long ago as 1815, has again recently been made the subject of discussion. In an able article on '^ Annular Stricture of the Intestine; its Diagnosis and Treatment,^* in the British Medical Journal for May 31st, 1879, Mr. Stephen Mackenzie wrote: ^^ The fact that full-sized, properly formed fasces are occasionally passed, of course shows that there can be no 1 ^* With regard to the lessened diameter of the faeces, just noticed, which must necessarily be the case whenever a permanently contracted state of the gut takes place; yet it has happened in some instances where that change had been ob- served, that, in a more advanced period of the disease, faeces of a natural size had occasionally passed. The knowledge of this circumstance I consider of some importance, inasmuch as, if properly attended to, it will prevent the practitioner from hastily concluding there is no stricture merely from an examination of the evacuations, when symptoms may otherwise indicate the presence of the disease." —'* Observations on Stricture and other Affections occasioning a Contraction in the Lower Part of the Intestinal Canal, etc.," Bath, 1815. NON-MALIGNANT STRICTURE OF THE RECTUM. 189 organic stricture." Under criticism, he withdrew the statement in the issue of the same journal for May 15th, 1880, with the explanation that it was founded on his personajl observation, which had since been supple- mented and corrected by that of others. In a case which I recently saw in consultation with Dr. De Long, of Brooklyn, I had a long-wished-f or opportunity to observe, in the presence of a number of physicians, the actual mechanism by which tape-like stools are produced. The woman suffered from a stricture one inch Above the anus, which was of sufficient calibre to admit the ends of two fingers easily. She had never noticed any deformity of the faeces. While under the influence of ether, and after the sphincter had been very thoroughly dilated, an O'Beirne's tube was passed through the rectum, which was empty, into the sigmoid flexure, which was full. After rest- ing there a few moments, it provoked a movement of the bowels. The stricture was instantly crowded down into view, appearing at the anus, ■and taking the place of the anus, which, owing to the complete dilata- tion, ceased to have any action, and was simply a patulous ring. Through the stricture there came a long, tape-like evacuation, the mould which gave it its peculiar form being the stricture pressed to the surface of the perineum, and greatly lessened in calibre by folds of mucous membrane, which were crowded into it from above. While remarking to those pres- ent on the peculiar mechanism of its production, the straining ceased, the stricture rose, the mucous membrane was relaxed, and a passage of natural formation was the resiQt. This alternation was repeated several times. At each violent effort the stricture was forced down to the anus, the membrane above it was crowded into it so as to greatly lessen its cali- bre, and a flat passage was the result. When the effort was less violent, there was still a passage, but the stricture having risen to its place, and not being so tightly filled with the mucous membrane, the passage was natural. The lesson to my own mind was this: that a stricture of large •calibre might, as a result of straining, cause a passage of very small size; And that, to get this peculiar shape, the stricture must be crowded down so as to actually take the place of the external sphincter, and be the last contracted orifice through which the soft substance is expressed. It is well known that, with the closest stricture high up, the faeces may be re- formed in the rectum below, and be passed normal in size. At the bed- side but little importance is to be attached to the statements of patients concerning this matter. After a stricture has existed for a certain length of time, signs of ob- struction will be manifest by abdominal palpation and inspection. The transverse and descending colon can be felt partially distended with masses of faeces, and will be dull on percussion, tender to the touch, somewhat movable, and pitting on firm pressure. After an attack of diarrhoea, or after a brisk purge, these accumulations may disappear, •only to form again in a short time. Generally complete obstruction does 190 DISEASES OF THE BECTUM AND ANUS. not occur without ample warning in this way. It is preceded by eructa- tions of fetid gas, the abdomen swells and becomes very tender on pres- sure, the coils of intestine are visible through the abdominal wall, and their visibly violent peristalsis gives proof of the effort nature is making to overcome the obstacle. After a short time the patient is exhausted, and, unless surgical aid is given, dies. Complete obstruction has been seen to occur very suddenly, forming almost the first intimation of seri- ous disease; and this is more apt to be the case where the stricture is high up in the rectum or at the junction with the sigmoid flexure. It comes on with the usual signs of acute intestinal strangulation — ^pain, swelling of the abdomen, bloody passages, etc., and it may be caused by some in- digestible substance which has been swallowed and refuses to pass the stricture, or merely by hardened faeces or prolapse of the bowel above into the constriction. The following case is one of quite a large class: ^^ The patient, a middle-aged woman, was admitted into St. Bartho- lomew's Hospital with symptoms of sudden obstruction. She stated thai she had enjoyed good health up to the onset of the attack, nor had she previously been troubled with constipation. The attack commenced sud- denly while at work, and was followed by obstinate vomiting and consti- pation. The symptoms having existed for some days, and the case appearing urgent, while the sudden onset of the symptoms suggested mechanical strangulation, it was deemed advisable to open the abdominal cavity. This being done, Mr. Marsh felt a hard cancerous mass in the walls of the bowel, which gaused the obstruction. The bowel was opened above the obstruction, stitched to the sides of the wound, the patient making a good recovery.* There is one important element in the obstruction due to stricture, which must not be forgotten. It will sometimes happen that fatal ob- struction will occur even when, on post-mortem examination, the calibre of the stricture is found to be large enough to permit the passage of the finger, showing that the obstruction could not have been due merely to the contraction of the new growth. John Hunter remarked a fact of this sort, as is proved by the following account: "On introducing the pipe by the anus, it was found to come butt against one side of the upper part of the cavity of the tumor, where there was a bend in the passage; but why a crooked pipe did not pass when attempted to be passed by turning it to all sides, I cannot conceive, or, why a bougie which was slightly bent did not hit the hole, is not easily accounted for; but, what is more extraordinary than either, why a clyster did not pass freely up; or why did not the wind or soft excrementitious matter that did yet lay [sic] pass readily down, while I could pretty readily pass the end of my finger down from the gut above into the * Cripps, Cancer of the Hectum, p. 107. NON-MAUGNANT BTBIOTUBB OF THE BEOTUM. 191 tumor? The folds of the contracted part did not appear after death to have been sufficient for an entire stoppage of this sort/^* Notwithstanding the statement that the folds of the part did not appear after death to have been sufficient to produce the stoppage, it seems that a prolapsed fold of mucous membrane is the only thing likely to give rise to it. In cases of advanced disease a spasmodic stricture (if such ever occurs) would seem out of the question, whereas partial or complete invagination in this part is known to be of frequent occurrence. As shown by Bokitansky,* the paralysis above the stricture is also an un- doubted element in the production of the occlusion. Diagnosis. — The first means of diagnosis in stricture is the examina- tion with the finger, and as the great majority of strictures are confined to the lower portion of the rectum this is in itself generally sufficient. It. is the best and safest and least painful of all the means of diagnosis when properly executed, and yet it may be the immediate cause of death to the patient when roughly practised. There is an inborn tendency on the part of many, when the index finger comes in contact with a tight stric- ture, to bore through the narrow passage which is left and feel what is on the other side^a tendency to be struggled against and overcome. If the surgeon has deliberately determined to practise divulsion, this is one way to do it, but at present we are speaking of diagnosis, and forcible dilata- tion is not diagnosis, but a very grave surgical procedure. The finger should therefore be passed slowly up to the stricture, and unless the cali- bre admits of it without straining, it should not be passed further. The= condition of the parts below may also be appreciated, the amount of in- duration estimated, and a general idea formed of the nature and extent of the disease. In women the vaginal touch will generally be found of the greatest value and should never be omitted. As a rule all can be learned in this way that can be learned in any other where the disease is within reach of the finger, and nothing is to be gained by a painful speculum examination or the use of the bougie- means of diagnosis which, however valuable where the stricture cannot be felt by the finger, are of little use for the lower four inches of the rectum. When a stricture is situated high up in the rectum or in the sigmoid flexure, the confidence in diagnosis which comes from actual contact of the finger with the disease is entirely lost, and there is perhaps nothing in the whole range of surgical diagnosis which requires more skill than the detection of stricture in this part, and nothing attended with more uncertainty. The symptoms of stricture of the upper part of the rectum are not the same as when the disease is lower down, for the nerve-supply is not the same, nor is the sphincter muscle involved. For this reason ' Hunterian MS. Cases and Dissections, No. 59, in ** Descriptive Catalogue," etc., voL iii., p. 98. From Mayo, op. cit., p. 249. ^ '* Manual of Path. Anat.," vol. ii., translated by Sieveking. 192 DISEASBS OF THE BEOTHM AND ANU& the patient is much more apt to suppose himself suffering from chronic constipation and dyspepsia than from haamorrhoids. Pain in the abdo- men^ not always localized at the left side, pain in the loins and down the legs^ obstinate constipation and occasional diarrhoea, are the things usu- ally complained of, and in these there is nothing upon which to base a positive diagnosis. The faeces may never present any peculiarity, for the reason that they are accumulated in the rectal pouch below the obstruc- tion and passed in the natural shape. They are apt to be lampy and unformed rather than misformed, but they may be streaked with blood or slime which is always a valuable sign and one calling for careful phy- sical exploration. A stricture in the locality in question must be examined for with the greatest care and gentleness, and the examination will often be negative in its results. The attempt to decide the question by the use of bougies is altogether unsatisfactory and by no means free from danger. It is unsatisfactory because an obstruction will generally be encountered in trying to pass an instrument of any considerable size through this part of the bowel, and the passage of an instrument of small size, which is much easier, proves nothing. It is dangerous because, with the ordinary rub- ber rectal bougies, a diseased bowel may easily be ruptured with what may seem to the operator to be no more force than is justified in attempting to overcome the natural obstructions to this part of the passage. The bulbous-pointed bougie on the flexible stem appears d priori to be the most suitable for the exploration, but it has two objectionable features. It is not at all an easy instrument to pass, and if passed through an ob- struction too much force is required for its withdrawal after the abrupt shoulder is in contact with the stricture. O'Beirne gives the following description of the way to pass his tube: ^^ A gum-elastic catheter of the largest size was inserted into the anus, and passed to the height of about two inches up the rectum, where its further progress was felt to be opposed by strong expulsive efforts, which lasted but a few seconds, then relaxed and again became renewed. By first yielding somewhat to these efforts, and then taking advantage of the succeeding relaxation, the instrument was gradually passed to the height of seven or eight inches. At this point the resistance was sensibly felt to be much greater than at any former, but, instead of allowing it to yield, the instrument was pressed more firmly upward. Having steadily continued this pressure for about one minute, the resistance suddenly gave way, the tube passed upward as if through a narrow ring," etc. Even with the softest instrument, the moment when the obstruction suddenly gives way, and the instrument passes forward, will be an anxious one for the surgeon, and the life of the patient may be sacrificed to desire for certanity of diagnosis. A bougie intended for this purpose should always be hollow and the opening at the lower end should be of a size to admit the small tube of a NON-MALIGKANT STRICTURE OF THE RECTUM. 193 Dayidson'B syringe which should be fitted to it before the attempt to pass it is begun. Then with a basin of warm water close at hand the bougie may be introduced and at the first obstruction the bowel should be filled with water until it is moderately distended. In this way the folds of mucous membrane are drawn out of the way by the distention of the whole bowel and one great obstacle is eliminated. The next is the pro- montory of the sacrum which is much more easily passed by a soft than by a stiff instrument. Without these precautions, and sometimes with them, the inexperienced examiner will find a stricture in the rectum of nineteen persons out of twenty, no ma^^er how healthy they may be; and for this reason it is seldom safe to rest the diagnosis of stricture on the fact that a bougie cannot be made to pass. Moreover a bougie of good size will often pass a stricture small enough to produce great trouble. In certain cases information may be gained by the use of a long cylin- drical speculum with the patient bending over the table or chair and straining down to bring the parts into view. Fortunately, however, we are not limited to either of