CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 8)

the purpose, and of inducing again the very condition it is desired to counteract, the consequences of which must be a confirmation and increase of the disease.^' The rules which should guide the surgeon in this method of treatment are now well understood and generally admitted. The dilatation should be intermittent, and not constant. Attempts at constant dilatation by means of bougies of any sort which shall remain permanently in place generally result either in failure or actual disaster. They are not well borne by the patient, and when their use is persisted in, in spite of the protest which nature is pretty sure to make, the rectum becomes irritable, the suffer- ing is greatly increased, and the. patient is exposed to the risk of peri- tonitis and cellulitis. The dilatation should never be forced. A bougie should be chosen which will readily pass the obstruction without stretching, and if there be any doubt in the operator's mind as to the proper size of the instru- ment to be used, let one be selected which is too small rather than too large. The instrument should seldom be passed more than every alter- nate day, and once a week may be often enough. Little is gained by allowing it tQ rest for any length of time within the constriction. Practised in this way, much good may be done by this treatment. The patient may be greatly relieved, and made very comfortable; but it I must be continued indefinitely. For this reason, I suppose it is not infrequently used under false pretences in cases of hypothetical stricture in hypochondriacal patients; and most of the reported cases of cure will be found reported by the laity. It has happened to me more than once not to be able to find any stricture after a patient had submitted to a long course of supposed dila^tion, and there is but one way of con- vincing the patient under such circumstances. It consists simply in passing a full-sized instrument its whole length into the bowel. In cases where the stricture is associated with much ulceration, dila- tation by bougies is very apt to make matters worse instead of better, and in such cases I seldom employ it in my own practice and have seen much suffering caused by it in the practice of others. This treatment by gradual dilatation, perhaps on account of the recent great advances which have been made in the treatment of stricture, has, to a certain extent, been superseded by more radical measures. It is not long since a well-written article on rectotomy in one » Op. cit., p. 120. 200 DISEASES OF THE RECTUM AND ANUS. of our periodicals was begun by the statement that the treatment of stricture by dilatation was acknowledged to be a failure. This is by no means the case. The measure may not be curative, but it is, perhAps, as valuable a palliative as is at the command of the surgeon. It need not always be done with a bougie; for the patient's own finger or that of a careful nurse is often better than any instrument It is applicable to all strictures, malignant or benign, which arc within reach of the anus. When the disease is high up, it is not free from danger, and can scarcely be recommended, on account of the uncertainty and difficulty of its application. I have said that this treatment by gradual dilatation was not curative, and must be continued indefinitely. I have seen no exceptions to this rule, though many of them are reported. In years gone by, this treat- ment and that of forcible dilatation or divulsion were about the only means of dealing with this affection. Now we have better ones which will shortly be described. Divulsion. The dilatation, instead of being gradual, may be sudden and complete. For this purpose, various instruments have been in- Fio. 49. vented, all of them with the idea of tearing open the constriction by the use of a considerable amount of force. One of these is shown in Figure 49. More recently, advantage has been taken of fluid pressure, and an instrument has been invented by Wales, which is shown in Figure 50. • Of all the instruments for forcible dilatation, this is perhaps the best. There are now several cAses on record where forcible stretching with thd fingers, either with or without previous nicking with a knife, has been followed by immediate relief to obstruction and faecal accumulation. « What may be accomplished by this nuithod is well shown in the fol- lowing successful case from Smith.' "I was called by Dr. Vine to see a military officer, aged 40, who had returned from India in the most mis- erable plight. He had suffered for several years from chronic diar- rhoea, and had not got relief from toy measures, and six months pre- viously he had been recommended by a medical board to go by sea to England. On his arrival at Southampton, on his way to Edinburgh, his native town, he was so ill that he determined to stop in London, and > Smith, op. cit. Dr. J. M. Matthews, of Louisville, Ky., has recorded one remarkably successful case of this kind. * Surgery of the Rectum. NOH-HALiaKAKT 8TBIOTDBB OF THR BKCTDH. 201 when he srrived there he sent for Dr. Viae, who, on hearing his his- tory, at once suapected something wrong with his rectum, and making an I I examination, fonnd an obstruction. I was requested to see him, and I found the patient exaotly in the condition of one softering from straugn- 202 DIBEABES OF THE BECTUM AND ANUS. lated hernia; he was constantly vomiting, complaining of pain, and the countenance was anxious, and he was much emaciated; the abdomen was immensely distended, and it was clear that^ if some relief were not soon given, this gentleman would die. "In conjunction with Dr. Vine, I made a most careful examination, and I found, on introducing the finger into the bowel as far as possible, that it met with an obstruction, but after some time I discovered what appeared to be the opening of the stricture, more like a dimple than aught else. I was enabled to introduce through this a No. 10 gum-elas. tic catheter, and through this instrument some fsecal matter and air came. I was thus made to see that I had got beyond the stricture. " On the following day, the patient was placed under chloroform, and I guided a long, straight, probe-pointed knife very carefully along the side of my left index finger, and fortunately got its point into the orifice of the stricture. I nicked this on either side, and then got the point of my finger into the obstruction, and dilated the orifice as much as I could, whereupon an enormous quantity of faecal matter was emitted, deluging the bed, and placing myself and my assistants in a most unenviable posi- tion. The abdomen became quite fiat, and the patient became at once immediately relieved. No bad results followed this operation; in three days we commenced dilatation by bougies, and I was soon enabled to pass a full-sized rectum-bougie through the stricture. In a fortnight I took my leave of the patient, recommending Dr. Vine to pass the bougie daily. I heard a few weeks afterwards that the patient had gone to Edinburgh convalescent, and able to introduce the bougie for him- self." In spite of a few such successful cases as the one above, this method of treatment has but few upholders, because it has been found to pos- sess no advantages over more gradual dilatation, and to be in itself by no means devoid of danger. The dangers are haemorrhage, laceration and rupture of the bowel, peritonitis, and abscess. The relief ob- tained is not permanent, and the operation involves the subsequent use of gradual dilatation to preserve the calibre gained. Even when applied to the lower three inches of the bowel, the operation is rough, uncertain, and unsurgical, and above this point it is scarcely admissible. Nevertheless, it has occasionally served a good purpose, and a few happy results are recorded m cases of linear contraction. Division of the Stricture. — The practice of nicking a linear stricture in two or three places as a first step in the treatment by dilatation is a good one, and generally devoid of danger. It can usually be done en- tirely by the sense of touch with a straight, blunt-pointed bistoury passed along the left index finger as a guide. The operation of internal proctotomy consists in dividing the whole of the stricture tissue in the median line, either anteriorly or posteriorly. It is called internal because the incision is confined within the rectum. ; NON-MALIGNANT BTRICTURE OF THE BECTUM. 203- and does not involve the sphincter; and it is generally performed with the knife in preference to the cautery or 6craseur. Eegarding this operation, there is not very much to be said. It in- volves no new principle of treatment, and would seem to rank rather with the older procedures, such as nicking and dilatation, than as a sub- stitute for colotomy. There have been many unpublished cases, espe- cially in New York, and I should probably express the general feeling of the profession, were I to say that it is not looked upon with very great favor. Though at first sight it might appear less serious than the ex- ternal operation, it is probably the more dwigerous of the two — the sphincter preventing the free discharge from the wound and increasing in this way the liability to pelvic inflammation. This muscle should at least be stretched as a primary step in* the operation, and, when possible, a large drainage-tube should be left in. The danger of haemorrhage is not very great when the incision is confined to the median line, but, should there be trouble from this cause, the advantage of a free external wound in controlling it will at once be manifest. When the cut is ante- rior as well as posterior, the anatomical relations must be borne in mind, lest the peritonaeum in the female, or the bladder in the male, be wounded. The following case represents my entire experience with the operation, which I abandoned after once trying, being convinced of the advantages of the external incision, next to be described. Case XIX.— ^Mrs. , age twenty-six. This patient was a womaa with a syphilitic history. The stricture was of eight years' growth, and had previously been treated both by nicking and by gradual dilatation. As a result of this treatment, she describes an attack of ^^inflammation of the bowels," which made her very dangerously sick. The stricture was two and one-half inches from the anus, was of just sujfficient calibre to engage the end of the index finger, and did not involve more than one inch of the bowel, though there was the usual amount of ulceration above it. I divided the stricture by a single, deep, posterior incision, which did not implicate the sphincter, and the operation was followed by an att.ack of pelvic peritonitis, which very nearly cost the patient her life. This may have been due to the operation, or it may have been due to attempts at subsequent dilatation which was begun early and followed with perhaps too great vigor; but it was certainly excited by the patient leaving her bed, going down-stairs, indulging freely in wine, and submit- ting to the embraces of her lover. Three months after the operation, I completely lost track of the case. At that time the calibre of the stricture was so much increased as to per- mit of easy digital examination of the parts above. The increased size seemed due entirely to a deficiency in the old cicatricial tissue at the point of incision; the rest of the circumference of the part having much 204 DISEASES OF THE RECTUM AND ANUS. the same feel as before the operation. The act of defecation was much less painful^ and her condition was altogether much better. I never counted the case as proving anything concerning the value of the operation until a few months ago, and more than four years after its performance. In fact, I had little doubt that the contraction had re- turned, and supposed the patient had either succumbed to the disease or submitted to colotomy. At that time, however, the woman was in per- fect health and spirits, and since then I have thought better of the ope- ration. I would have given much for a rectal examination after bo long an interval, but it could not be obtained. Other cases of simila9 operations have been reported in this country with equally good results. * External proctotomy involves not only the division of the stricture, but of all the parts below, including the anus. This is the operation usually accredited to N61aton, and more recently advocated by Verneuil, Panas, and others. It may be performed in several ways, and with the knife, galvano-cautery^ or ^craseur. The operations with the galvano- cautery and 6craseur were invented by Verneuil,' and have been practised by him more than by any other surgeon. The operation as performed by him consists in passing the left index* finger through the stricture as a guide, and then plunging a trocar from a point in the median line, just in front of the tip of the coccyx, into the rectum, on to the tip of the finger above the stricture. After drawing out the trocar, a fine bougie is passed through the caniila into the rectum, and brought out at the anus. Removing the canula, the bougie is replaced by the chain of the 6craseur, and the operation is com- pleted. The same section may be accomplished by repeated strokes of the gal- vano-cautery or thermo-cautery knife. Both these measures are intended simply to prevent haemorrhage, and have no other advantage over the knife, and by any of the methods all of the stricture tissue and the parts below may be divided. ^ Whitehead — Old fibrous stricture: anterior and posterior incision with bis- toury, followed by dilatation. Two months later, much improved; passages large and natural; dilatation continued. Amer. Jour. Med. Sc, Jan., 1871. Lente — Fibrous stricture and fistula; incision followed by dilatation. Three months later, much relieved, with prospect of entire cure by continuing the use of bou- gies. Amer. Jour. Med. Sc., July, 1873. Beane— Probably syphilitic; incision both anterior and posterior, followed by use of dilators. Seven months after, cure of ulceration and of many bad symptoms, but tendency to recontraction. Amer. Jour. Med. Sc., April, 1878. ' Verneuil : Des retr^cissements de la partie inferieure du rectum, et de leur traitement curatif ou palliatif par la rectotomie lineaire, ou section longitudinale de rintestin k Taide de TScraseur. Gaz. des Hdp., October 26th, 29th; November 7th, 9th, 12th, 16th, 19th, 1872. Traitement palliatif du cancer du rectum au moyen de la rectotomie lineaire* Gaz. Hebdom, March 27th, 1874. NON-MALIGNANT BTBICTURE OF THE RECTUM. 205 N^aton's method was the simplest of all, and was to introduce the left index finger as far as the stricture, and with this as a guide, to pass in a blunt bistoury, and divide all the soft parts below the stricture as nearly as possible in the median line. By pulling open the lips of this incision, the stricture comes plainly into view, and may be divided by a second incision. In performing the operation, I prefer the knife to all other methods of cutting, and have had one specially adapted for the purpose, which is shown in Fig. 51. It is simply the lithotomy knife of Blizard, made heavier in the back and at the handle, for with an ordinary bistoury there is great risk of breaking the blade in the midst of the stricture tissue, which is often as hard as cartilage, and thus having an awkward accident. The blunt point on the end of the blade is a great convenience in passing the knife along the index finger, avoiding as it does, all risk of wounding the operator. The best position for the patient is the lithotomy position, and the whole incision may be made at one stroke. The blade should be passed fairly through the stricture before the cutting is begun, then the stric- ture is divided completely, as near as possible in the median line Fig. 51. posteriorly, and finally the incision is continued downwards and out- wards, growing deeper as it approaches the perineum, till finally all the soft parts are severed between the anus and the tip of the coccyx. In this way, a large triangular wound is made, the apex being within the rectum, above the stricture, and the base at the skin, and all the stricture tissue is completely cut through. There will generally be a free gush of blood when the cut is made, but I have never seen so much as to make me prefer the ecraseur or cautery operation in preference to the knife. The rectum should at once be packed in the manner already described, without waiting to try any other method of stopping the bleeding. This is a precaution which should never be omitted. This operation may be modified in various ways to fulfil any special indication. In extensive cancerous disease, I have sometimes made two such cuts, and taken out a considerable mass of the growth between them, merely for the purpose of opening the canal. It may be asked. Why should so large an incision be made, and so much tissue be divided below the actual disease? The answer is simple. In the first place, this incision provides for free drainage and discharge in the most effectual of all ways, by furnishing a dependent gutter- 206 DISEASES OF THE BECTUM AND ANUS. shaped opening which cannot become closed. This is better than any