BMAGE EVALUATION TEST TARGET (MT-3) ^ ^ 1.0 l!l I.I 11.25 I. lis. 2.2 2.0 1.8 J-A ill 1.6 nl-_j. i_i_ riiuiugiHpmc Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^ m^ ^\ 4^, «^\ ^k\ 'O ?u .^ ' ^%^ !> 4.5^ .sigriifie "A SUIVRE", le symboia V signifia "FIN". Lee cartaa. planchaa. tableaux, etc., pauvent dtre filmte A dM taux de reduction diff«rents. Lorsqua le document eat trop grand pour itre reproduit en un soul cliche, ii eat film* i partir da I'angle sup^rieur gauche, de gauche k droite, et de haut en baa. en prsnant le nombre d'Imagaa nteaaaaira. Les diagrammes suivants iliuatrent la m^thoda. 1 2 3 1 2 3 4 5 6 I X t^ct e^^^^n) ^^^^' <' / • I f \ ^v /'c e^^-^ ^^ ' / iff HORACE NELSON ON STRICTURE OF THE RECTUM. ..',' . ! t r TJ' STRICTUKE OF THE RECTUM; I' ITS HISTORY, SYMPTOMS, DIAGNOSIS, PATHOLOGY, AND SUCCESSFUL TREATMENT BY INCISION BEING AN INAUGURAL DISSERTATION Jor t^e IrUtsIj ^tgret of ^octor of MtVxcint. Wimbmitu of PciiHI m^'ml Colltgt, May 3, 1861. BY HORACE NELSON, M. D., Knibcreitg iffietical CoIUgf, i^cto gorft ; Late Editor of '^Nelson's American Lancet ;" one of the PhysiciaJw ' ' to the Montreal Dispensary, &c., &c., &c. ■y'"-""'" MONTREAL : JOHN LOVELL, CANADA DIRECTORY OFprOE, ST. NICHOLAS ST. 1861. I TO WILLIAM SUTHERLAND, M. D., Iroftssor of C^mislrg in t^t mmfetrsilg of Pt«iU gltiiital «oUtg«, HT IF-ORMER COLLEAGUE IN THE SCHOOL OP MEDICINE OF MONTREAL, ^ost Social gillribules ABl ONLY EQUALLED BY HIS HIGH PROFESSIONAL ATTAINMENTS, TBK rOLLOWINQ DISSERTATION 13 RESPECTFULLY DEDICATED, §s a Blight a;rib«it of irunbs^ip anb «siwnr, BY THE AUTHOR. ■I ,4 /v ,4 STRICTURE OF THE RECTUM. /v \ I. History. Diseases of .h« Eectam .nd Anu., ■„ „„„ ft™, „, „„a „^ ^^ argoon, f I tho, have made ™ch prog«»,, „„. „„,, t, a^,, ,^, J ^; tte^ d.,astro„= mroads upon .I,e .y„e„ al largo, that thoyoan no longc be dif th the advce of the s„,geon is sought for. No, i, thU s„p«„g, seeing Z of he lower bowel i, f„„„d in a More „, le., eonstant and of.enti«, .i.tZ » at of eonsfpafon, preeeded or aeeompanied with various derangement, 'h! ohjlopoielio viscera. o'-monta ol th« Of tl>e several affeetions of the Rectum for which surgical aid is at time's re ,u„.d, «,™,.„ of .his portion of the alimentary canal though not of ^^^^ Mon occurrence, . one that rc„uires much dl.rimin.tio„ on the part of .11 geon, 10 fully and clearly understand the various causes that may induce Z deplorable state of things, „„d also the best means of remedying 1 v" .f unchecked ,n .ts eourse,-„nd this is too often the ease [n L hands' Tit young, uncxpcnenccd, or thoughtless praetitioner.-tiU reUef is beyond reach and death .s staring both patient and attendant in the face, when the ol^: na..vc. a very precarious and loathsome one. an artificial anus, pLnt. Having within the last few years seen seven cases of Stricture of the Bectum .nd treated sh of them upon a plan different from that generaUy adv J by ,t cogntsed author,t,cs, and with entire success, a short history of this affeetioa may not prove umntcrcsting to the junior practitioner, whilst to those who m.v have grown grey in the service, and have long been wedded to preconceived 6 STRICTURE OF THE RBCTUM. opinions, it may not be entirely benoath their notice. In the preparation of this paper I have availed myself of the labours of those who from chance or inclina- tion, have been thrown in the way of making something of a specialty of this affection, and who are justly considered as orthodox upon the subject; in all cases where it was deemed proper or requisite, due credit has been awarded, and if I have dissented from long entertained and tim j-honoured views, more par- ticularly upon the treatment, it has been because I have thought proper to leave a well-beaten track and strike out a new path for myself, and with what suc- cess my readers will be the best judges. I cannot probably find a better preface to this paper than by the translation of an extract from the very practical monograph of a distinguished French sur- geon :— " There is one fact, at once curious and important in pathological ana- tomy : it is that of all the portions or divisions of ihe alimentary canal, those that are normally of a contracted calibre, are the more ordinary seats of very serious alterations. In these narrowed portions, the blood vessels are more nu- merous, there is an increased degree of sensibility, the follicles are more devel- oped, the texture is thicker and more compact, and the organization more com- plicated. It is here that we find s!oj.^H„g places called for by the functions to be carried on immediately above; here the contact is harsher, there is sometimes a species of elective organic action which will either permit or refuse the passage of foreign substances, depending upon the properties they may possess or may have acquired. Is there acute inflammation, the points I am indicating are the ones where it rages with the greatest severity, or accompanied by a special class of symptoms of an unusually intense description. Is it a case of chronic inflam- mation^or of one of those irritative aflfections which, after having implicated a large extent of surface, becomes limited and centered upon certain points, then rest assured that you will almost always find them in the regions alluded to, causing changes of structure, deep disorganization, and the creation of various morbid products, all of which so frequently baffle the most judicious and scien- tific efforts of the practitioner. These culminating points in pathology, if I may be permitted ihe expression, arc the isthmus of the fauces, the esophageal opening, the cardiac and pyloric orifices, the neighbourhood of the ilio-caecal valve, and lastly, the lower portion of the rectum and anus. Examine cases, open bodies, and you will find that the very great majority of morbid affections, and more particularly those of a chronic nature, of the alimentary canal select these points not only as their origin but as their principal or exclusive seats. The termination of the large intestine, and the opening in which it is insen- sibly merged, are endowed with all the conditions necessary to render their / \ r ^ I > j STRICTURE OP THE RECTUM. J lesions at once of very free, .t occurrence, and of a very serious character. A double muscular ring around the anus, opened only by superior muscular power j large mucous follicles intended to favour the easy passage of the excreUons • a high degree of sensibility, oftentimes morbidly exalted; a receptacle wherlin irritating substances accumulate by their volume, their consistence or compo- sition ; in both sexes the proximity of the most active portion of the genito-uri- nary organs, whose excitations, congestions or pathological changes promptly ex- tend to the surrounding organs; finally, fits of coughing, even the mere effort of talking, severe muscular action reflected upon the anal region, press and there confine venous blood; such arc some, th.mgh not all, of the principal conditions of structure, of functions and connections, which render the rectum and anus of such importance in pathology. These considerations could not fail to strike the mind and arrest the atten- tion of the observing practitioner; thus many of the diseases of the terminal portion of the digestive tube, supposed formerly to be of rare occurrence because they were imperfectly understood, have been more attentively studied durin- the last twenty years, and have become very lately objects of special if not general attention."* ^ II. Surgical Anatomy op the Rectu.m. It will not be out of place, at the onset, for a proper understanding of our subject, and a full knowledge of the parts implicated in stricture, and more par ticularly in relation to the surgical treatment, as will liereafter be demonstrated to be the only correct and permanent mode of treating this affection, to trace a brief sketch of the surgical anatomy of the rectum. This portion of the intestinal canal- variously estimated by anatomist^ to be from six to nine inches in length-is continuous with the sigmoid flexure of the colon, opposite the left sacro-iliac symphisis, and passes obliquely downwards to the right where it rests upon the middle of the sacrum ; now it continues down wards moulded upon the curvature of the sacrum and coccyx, next it inclines somewhat backwards and forwards to terminate at the anal orifice, or more cor rectly speaking, at the upper fibres of the external sphincter muscle. The rectum -one of the many anatomical misnomers-will now be seen to be far from being a straight canal as its name would otherwise imply, has been divided into three portions. The frst, or u^fer portion, from three to five inches in length, extends down- wards and to the right from the left sacro-iliac symphisis, to the middle of the third sacral vertebra; it is invested by peritoneum on its anterior, lateral, and • J. L. B^gin, Annales de la Chirurgie Franjaise et Etrangere, 1841 ; volT^TTisO. 8 STRICTURE OF THE RECTUM. two-thirds of its posterior surfaces, where the serous membranes of the opposite sides unite to form the luoso-rectum, which attaches the gut, rather loosely, to the upper segment of the sacral bone. Posteriorly it rests upon the pyriform mus- cle, and ,s separated from the sacnm and its iliac junction by the saeral plexus of nerves, the branches of the left internal iliac artery, the superior hemorrhoidal or terminal branch of the inferior me«eaterie artery, and lastly, by loose cellu- lar tissue; anteriorly, the peritoneum is reflected from the intostine upon the posterior surface of the uterus, and its appendages in the female, and upon the posterior surface of the bladder in the ma'e, at a distance of from four to five inches from the anus, forming a pouch in which are lodged some portions of the small intestines. _ The second, or middle ^o,-^;o», varies from two and one half to three inches m length, and extends from the middle of the third bone of the sacrum to the prostate g]a.d , it follows the curvature of the sacrum and coccyx, and has the least lateral deviation of any portion of the gut. Posteriorly, it is loosely con- nected to the bones by cellular tissue ; the peritoneum only and partially invests Its upper and anterior surfaces; anteriorly, it is i„ relation with the prostate gland loose cellular tissue intervening, next we have the vesieula. seminales and vasa deferentia, leaving a triangular space where the trigone of the bladder is only separated from the rectum by a layer of adipose tissue; in the female the vagina is directly in contact with io, forming the recto-vaginal septum. ^ TU third, or inferior ^om-o«, the least in anatomical importance, is fromone -0 one inch and a half in length, and extends from the prostate gland to the anal orifice; it is directed obliquely downwards and forwards, and has no con- nection whatever with the peritoneum ; it is encircled successively by the inter- na sphincter, the levator ani, and the external sphincter; it is imbedded in the fatty deposit of the ischio-rectal fossa ; and hence, when abscesses are formed in this legion, their well known tendency to infringe on the calibre, and interfere with the action of this portion of the intestine; in ihe male it is separated by a small triangular spa«e from the bulbous and membranous portions of the urethra, while in the female, the same space exists between the vagina and the rectum. From the foregoing brief description it can now be clearly seen that the im- portance and extent of the peritoneum-the great dread in cutting operations upon the rectum-has been, to say the least, very much exaggerated ; it only invests the upper and lateral surfaces of the first portion, but a small part of the anterior surface of the second, and is totally unconnected with fhe *hird pMion In fact, Velpeau* says that the last four or five inches of the rectum (the A rrait6 d'Aratomie Chirurgicale dea Regions, t. II, p. 322. Paris. 1826. A STRICTURE OF THE RECTUM. 9 usual scat of stricture,) have no immediate connection with this serous mem- brane. A few words now concerning the mucous membrane of the intestine which from Its looseness and numerous folds, has always been a fruitful source of error and doubt in explorations by the bougie. This membrane is thicker, more vas- cular, and more loosely connected to the muscular coat beneath than at any other portion of the large intestines; hence the resistance offered to, and the lability of stoppage of the bougie. In its contracted state, the lower portion of the rectum is thrown into a number of longitudinal folds, denominated the CO umns of the rectum; again the mucous membrane forms the three prominent valvular folds of Houston, all directed obliquely ; one is found at the commence- ment of the rectum, this is the great stirMng point, near the right sacro-iliac symphisis; a second extends inwards on the side opposite the middle portion and the third projects backwards, from the front part of the rectum, opposite the prostate gland, -he situation and direction of these folds should be care- fully remembered to ensure the safe and complete passage of the bougie throu-^h- out the extent of the rectum. Another reason why strictures are not treated I y the use of the knife has been from fear of /..»o.r/.,^.. Let us point out the sources whence the bleeding may possibly arise :-lst. The superior hemorrhoidal, the terminal branca of the inferior mesenteric artery, descends between the layers of Uie meso- rectum and opposite the middle of the sacrum, divides into two branches which ramify between the mucous and muscular coats to near the termination of the intestine, where they anastamose with each other, and with 2nd, the inferior hemorrhoidals, two or three small branches sent off by the internal pudic artery near the tuberosity of the ischium, which cross the ischio-rectal fossa, and are distributed to the muscles and integuments of the anal region. The middle sacral, from the bifurcation of the abdomina^l aorta, and the lateral saerals, the last branches of the internal iliac arteries, snpply no branches to the vectum, and could scarcely be implicated in any operation performed upon the part, unless the whole thickness of the bowel were incautiously divided down to the bone, either in the mesian line, or about one inch on cither side of it It will now be seen, therefore, that the hemorrhage can only proceed from the branches of the superior hemorrhoidal; and as the incision is generally made on the sacral aspect of the intestine, and presenting, consequently, a firm and un- yielding base, I cannot conceive but that the bleeding could be rea.lily and speedily controlled by properly applied pressure. 10 STRICTURE OF THE RECTUM. III. Frequency of Stricture, and the influence of Aok and Sex UPON ITS Development. It is occasionally observed in practice, as a singular coincidence, that several cases of some rare disease will, at times, present themselves in rather rapid suc- cession, and this I have found to be true in relation to the subject under con- sideration, having seen seven examples of stricture of the rectum in the last few years. However the affection cannot be considered as of frequent occurrence, as is proved by the assertions of these who enjoyed a deserved popularity in the treatment of this disease, and whose opportunities were far from being limited. " It must not be supposed, as some writers would lead us to do, that stricture of ' the rectum is a very frequent disease In a large parochial infirmary in which I have had opportunities of examining many bodies, I have seldom dis- covered stricture of the rectum."* Again, " organic stricture is supposed by many to be of very common occurrence, but I have not found it to be so; for the cases I have seen bore no proportion to the number I ought to have met with, were the statementn made in books correct."f Age appears to exert little or no influence on the development of stricture, though it is generally of more frequent occurrence in old persons; its average- rate may bo reckoned as between the 25th and 60th years. Bushe J records the death of a man from this affection at the advanced age of 72. Sex ; Dessault,§ from his observations made during a long-term of service ax, the Hotel Dieu, Paris, states that stricture is much more frequent in women than in men, in the proportion of one to ten. Ashton || says that the propor- tion is about equal in the two sexes. Bushe,^[ in his fifteen reported cases, mentions having mot with stricture in only eight women. Erichsen** says that it is met with special frequency in women. Of the thirty-one cases I have collected, twenty occurred in men and only eleven in women ; of my own cases, four were men and three women. IV. Causes. Although in some extrem-ly rare cases, stricture of the rectum has been known to come on s pontaneous ly, yet its exciting source, if not direct origin, is found Lonlon," tafl'p. ^^^''''''^^^^^^^^^^^ t George Buahe Treatise on the Malformations, Inj,.rie., and Diseases of the Rectun>, and Anus. New York, 1837, p. 2G4. t Op. cit. p. 259. § (Euvres Chirurgicales, par X. Bichai, vol. 2, p. 422, Paris, 1813. Lit. 30. I Op. ^ Op. cit. p. 48. "Science and Art of Surgery, edited by Brinton, page 759. Ph .' V liladelphia, 1834. STRICTURE THE RECTUM. 11 V in inflammation in or about the par -If; and this inflammation may be in- duced by a variety of causes which i:iay be classed as accidental, while others ^nay he more j.roperlt/ considered as local or constitutional. Among the accidental causes w^ have the presence of foreign bodies thrust from the exterior, the lodging of some substance, the retention of portions of clothing or other materials in the gut or its immediate neighbourhood, setting up a degree of irritation that leads, sooner or later, to an effusion of serum or coagulable lymph in the coats of the bowel, or in its cellular investment, which becoming more completely and thoroughly organized, induces degeneration and alteration of the tissues, and with this, necessarily, a commensurate degree of contraction of the bowel, which, if unrelieved, will lead to a complete closure of Its canal, and the lingering and agonizing death of the patient. It is a singular fact that this unfortunate result is more to be looked for after some slight injury, such as a fall or blow upon the nates or anal region, than when the injury has been from the first, of a most serious, if not very doubtful nature. Well do I remember seeing in the hands of my venerable and distin- guished teacher of surgery, Valentine Mott, of the University of New York, an enormous angular stone,that had been forciblydriven base foremost into the rectum of a drunken fellow, by some equally drunken associates, just for the " fun of the thing," and which remained concealed in its novel situation for some ten days, producing obstinate constipation and its many and varied accompaniements, and had baffled the hkill of several eminent medical men. The Professor's advice was requested; he made a close and critical examination,— the patient not be- ing able to give any account himself— and soon discovered the source of the trouble, but did not so soon find the means of dislodging the intruder; and it required all the mechanical and surgical ingenuity with which he is so pre^jmi- nently gifted, to succeed in performing successfully the only operation on record, I believe, of lithotomy in the rectum. The after treatment was carefully at^ tended to, the man recovered, and was living several years after free from any inconvenience whatever. Again, that foreign bodies may remain for some years imbedded in the immediate vicinity of the bowel, implicating its tunics and in- fringing upon its diameters, without, however, the production of very serious, if any evil consequences, is proved by an interesting and novel case I communi- cated lately to the pages of the Britim American Journal of the Medical and Physical Sciences of this city.* Operations performed in the perineal or anal regions for the cure of fistula-in- ann, or the removal of hemorrhoidal growths, l.ave been known to be followed with the amount of^rritation reqmsite to induce contraction ; yet it h emphati- * March, I860, p. 99. 12 STRICTURE OP THE RECTUM. cally asserted " that no operation for the cure either of hemorrhoidal tumours or fistula-in-ano, ever did, or ever will, tend to the production of stricture or other diseases of the gut, provided the operation is rightly performed, and that proper attention is -xfterwards paid to the general health of the patient."* After this unqualified assertion, the reader will not be a little surprised to hear that the same surgeon, in his reported cases, mentions no less than two in- stances where the stricture followed his operations for the cure of fistula-in-ano.f We must, in all kindness, presume that the operations were rightly performed, and that the necessary care in the after treatment and general condition of the patient had been attended to, and still stricture was the result. Therefore, we must class as among the occasionally accidental causes of stricture of the rectum, operations performed upon this portion of the alimentary canal. Of the load, predisposing, or constitutional causes, as has already been said of the other diseases of the bowel, constipation, by whatever cause it may be in- duced, stands in the first rank as productive of stricture ; the hardened fajces passing slowly through the intestine are retarded by its various curvatures and the folds of its mucous membrane, accumulate and distend the part, thereby ex- citing an undue degree of irritation and pressure, resulting in a low-chronic form of inflammation and its sequences : in acrimonious or acid condition of the alvine excretions; the never ceasing irritation of protracted diarrhoea, and more particularly of dysentery, and the cicatrization of ulcers frequently attend- ing these complaints ; functional disorders of the stomach and its accessories, more especially the liver ; the development of adventitious structures in or around the bowel, such as adipose, and less frequently, though certainly not the less fortu- nately, scirrhous tumours, though a contrary opinion is entertained by a distin- guished riter, who says that malignant structural change is of more common occurrence than simple degeneration. J Exostosis of some portion of the sacral or coccygeal bones ; an enlarged and indurated prostate gland, and a misplaced uterus, have all, at various times, been known to produce the afiection under consideration. The impaction of various substances after having been swallowed either inten- tionally or otherwise, may set up a great amount of irritation at the sigmoid flexure, not only causing stricture, but determining ulceration of the bowel, as was seen i\i an interesting case where a person had swallowed some hog's bristles.S * J. Howship, Practical obaervations on the symptoms, &c., of the diseases of the Lower Intestines and Anus. London, 1824, p. 3. fOp. cit., case 14, page 51 ; case 15, page 52. t James Syme, Diseases of the Rectum, 3rd edition. Euinburgli, 1854, p. 49. § J. Burrell, Edinburgh Medical Journal, vol. 9, p. 110. STMCTUBE OP THE REOTOM. jg Again it h„ been asserted, thongh I conceive without sufficient reo,o„, that .^*,e has arisen ,™n, the .e^st.™ „f ,,,;„ „,.„„„, affeetior* 'fl the suppress,„n of habitual di»ha,,es; sjphiiis ha. al» been looked Jn Z c^use . th.s can be r«dil, granted if there shonH be a direct app,iea.r„f h pec* n.a.tcr to the part prcduoing nlceraUon, cicatri».i„„ a Jeontrct „ o fte bowel, but .t cannot 1. admitted upon pure,, constitutional ground, ur^el a^^y eo^es to our assistance, fro„ what we .nowis of so f,e,„™. „ :t^ W Th?i rT'-' '" "'""""''' «-.I aDude.!the.„uthand fauces. The long, and ,ft.„ injudicious use of drastic pu,j-ati,es, or the incau .ous use of a sjringe, „.j .,„ he Wed u,,o„ as cciting if no di^tiri d,.pos,ng causes. Tanchouf ct. the case of a lad, who had had no ZZ >^ »»* ani „ U/,. .here was no stricture of any portion of .he i„«i!e andtheconst.pat,on„asdue to the inordinate and careless u. of i c* ' :e;:ir„:i:;^sr " *- ^-" ^^^ ^- - - — . - V. Variimes or forms op Stricture. Stricture of the rcctun, n,ay present itself under one of three fom,s -Is. S.»y«, brous or organic, with thickening of the mucous or .nuscular coa Jtf the bowel the result of ch,onic i„f.„,„ation ; 2nd. 5,«,w.-c, JZatil nanre nnphes, fron, abnorn,al action of .he sphincters, and .os gener* 2 accon,pa„,en,ent or s„.o. of hemorrhoids or uleera.ions of the n,en,bLe ^ VI. Seats op Stricture. U^d, to suff r f„,n, stricture; i. is said to have been found at distances varying from,,™ to, e»,„ches from .he anus. In .hir.y-one .cases, the striCuro ™ a^rt^ne^ to be at from ,„„ to /„.r inches in twenty cases from /J to Z .aches ■„ ton cases, and in onlyo„e case it is ..portod to hav existed ,1 inch" w, I, he^fore, be seen that in three out of every four cases, we are to look for fte etncure w,.h,n reach of the linger, that is from two to four inches up the bowel ,. and in those eases whero the assemblage of symptoms would LL to ■aspect the cstcnce of strict... though unaseertainable by the finger, an! rt cm.r^e«hadtoan^pb_r^^ ,„ J^ .,^^ ,«^ ; J. - • Dessault, op. cit., p. 423 ~~ ^ tjr.it. des Retreclsement; d« canal d« I'Ure.re et de rintestin Rectuu.. Paris, 1835, 14 STRICTURE OF THE RECTUM. tion is attended with much diiBoult3r, and is far from being conolusive or satisfactory ; the instrument may pass readily enough, perhaps, till it arrives opposite the promontory of the sacrum, when its further progress becomes sud- denly and abruptly checked, the extremity of the bougie being either entangled in the folds of the mucous membrane or striking against the bone. Consequently stricture at the sigmoid flexvre of the colon is to be looked upon as of extremely rare occurrence, and in many cases as very improbable. There are but few well established instances on record, ascertained positively only after death, as in the case of the great French tragedian Talma. In further illustration of this posi- tion, and the deception attending occasionally the use of the bougie, I will quote the following striking case : — " I was consulted by an elderly lady who had been supposed by two medical men of high respectability, to be suffering from stric- ture of the rectum, between 5 and 6 inches from the anus ; finding that the coats of the rectum, though greatly dilated, were quite smooth and apparently sound in their texture, as far as my finger could reach, and conceiving that the symp- toms of the case denoted a want of tone or proper action, rather than mechanical obstruction of the bowel, I expressed a decided opinion that there was no stric- ture in existence. Not many months afterwards, the patient died ; and when the body was opened, not the slightest trace of contraction could be discovered in the rectum, or any other part of the intestinal canal. One gentleman, who had been formerly in attendance, was present at this examination, and wishing to know what had caused the deception, which he said had led to more than three hundred hours being spent by himself and colleague, in endeavours to dilate the stricture with bougies, he introduced one as he was wont to do and found that, upon arriving at the depth it used to reach, its point rested upon the promontory of the sacrum."* It will not be out of place to quote a few extracts from well known writers showing very conclusively the great diversity of opinion in relation to this im- portant part of our subject. " Strictures are commonly situated in the lower part of the gut, within reach of the finger. Are they never situated higher up ? I saw one case where the stricture of the rectum was about six inches above the anus ; and I saw another case where there was stricture in the sigmoid flex- ure of the colon, and, manifestly, the consequence of a contracted cicatrix of an ulcer, which had formerly existed at this part. Every now and then also I have heard from medical practitioners of my acquaintance, of a stricture of the upper part of the rectum, or of the sigmoid flexure of the colon having been dis- • Syme, Op. cit., pp. 110-11. STRICTURE OF THE RECTUM. 15 Such cases, however, jou may bo assured are of very rare covered after death, occurrence."* •■ Anyone who maintain, that .triclure. c.i,t at to or tete inches, and «% fc..,. the pat,ent."t He allndes in one of hi» Ie„,„„. ,„ , ,„.„ y^ p who had been treated b, bougies for a ..rie.nre of the reetnm, at .he h eight ^ **« .nehes! It . needle,, to say, that the poo, fellow after long and patieu "The most usual seat is /,.o to t'A.e« inches from the anus- occasional!, and the. absolute ex.tence has not generally been known till after death "t The situation in which we meet with strictures of the alimentary c,n«l • «iost commonly about the termination of the colon."§ ^ '' '' " These, however, must be veiy rare eases, for all the best authorities deolnr. the stricture to be almost universally low down."|| ^"' "In the majority of cases which have fallen under „,y observation the «. • tare has been situated between/, and .-. inches from the a uT' abl ^ «tuation c,- the angle formed by the first portion of the rectum Ne:; qucney, I have discovered the disease at the junction of the sigmoid fl. I the colon with the rectum."^[ '= ^ ^'^"""^ «" Vir. Symptoms of Simple Stricture. The symptoms of simple stricture may be very properly considered und. t^e heads of special and general, or local and consaJonll ' 1. Special or local symptoms. From the very onset the n-.f .- i» attracted to a ve, .Urac.n.a. ,y„,pto.. whfeh I^o'o 1''"'°? gr«„. ^.„ in the process of deflation, accompanied with a Z^ZV"- of »lra,»,ng, th,s is generally preceded by a constipated slate of th" b ! f "" promment and long precursory sy,„p.om-u,e st«,f, are «»n.v a d ,7 '"'' vcded taking on variable appearances, being either in smaTlultdt T'T !!:!p:^^:M^t^o,^^u^^^ • Sir Benj. 0. Brodie, Lectures on Diseases of the Rectum T nnZ~^7Tr~~~~ April 4, 1853, p. 30. «ectuni, London Medical Gazette, t Syme, London Lancet, April 5, p. 356. t Ashton, Op. cit., p. 289. § W, White, Observations on Strictures of the Rectum «„a „.u tion, Bath. 1820, p. 47, «ectum and other affection?. 3rd edi- " ^°"t''> Chelius' Surgery, vol. II., p. 33S. ^F. Salmon, Stricture of the Rectum, 4th edition. London, 1830, p. 23. 16 STRICTURE OP THE RECTUM. quill, and discharged in a convoluted or spiral form. Again, there may be a diaraet- rioallyopposite state of things.that of diarrhoDa,the fluid faeces being forceably and al- niobt involuntarily ejected,this last symptom is characteristic of the most advanced period of the disease ; lastly, the two conditions, diarrhoea and constipation, may be present at one and the same time. A small portion, the crust of the har- dened faeces which are retained in the rectum, becomes dissolved or diluted by the admixture of the intestinal mucus, and these matters are voided involun- tarily : the practitioner might be led to suppose that the case was one of diarr- hoea, when in reality it is one of const'qmtion, various astringent remedies are .. administered, anodynes freely given to allay the pain and other abdominal symp- toms, and yet the accumulation is allowed to increase daily ; the physician is acting upon a pretended cause, and necessarily the patient dies either from ab- dominal inflammation, or from the great and sudden weakness certain to follow the evacuation of the enormous quantity of matters distending the intestinal canal. Vidal (de Cassis)* relates that he was requested to see a paralytic patient said to have had diarrhoea for a very long period ; he had been drenched with rice water, and even leeches had been applied to the abdomen to relieve the colicky pains. The rectum was examined and found distended with a mass of hardened faeces, which was removed, and immediate relief followed. There was here then constipation and diarrhoea, retention and incontinence, as around the mass of indurated faeces were liquid matters, which escaped from the anus at every in- stant. The patient complains of a feeling of itching, heat, and weight about the anus; there is frequently a discharge of semi-purulent or mucous matters, and the faeces are occasionally tinged with blood. 2. Constitutional symptoms. From a very early period of the affection the digestive functions become impaired, and we have present many of the symptoms of dyspepsia ; more or less torpor of the liver, and hence the almost constant state of constipation ; the tongue is coated, and the appetite very capricious; flatu- lency, and spasmodic pain or colic in the abdomen, and, frequently, from ab- dominal distention the free play of the lungs is seriously interfered with ; the countenance has a dull sunken appearance, and, at a more advanced period, it is characteristically expressive of very severe uneasiness and anxiety, if not of con- stant suffering. There is more or less headache, and sleep is always disturbed ; the action of the kidneys is impaired, the urine being scanty and high-coloured, and its discharge is frequently attended with pain ; irritation of the bladder ; pain sometimes at the end of the penis after micturition. In the female there i* 't » * Traits de Pathologie Externe, 3me edition, vol. IV., p. 36T, PmIb, 1861. 't » STRICTURE OP THE RECTUM. 17 irritation of the uterus, accompanied with bearing-down or expulsive efforts- pans or cramps radiating around the pelvis to the back and down the thighs • at a more advanced period general debUity becomes one of the most prominent symptoms. If the index finger of either hand is well oUed, and very gently passed through the anus, it will in a great majority of cases come in contact, at a distance of from two to three inches and a half, with a hard, incompressible ring, havingbut a small perforation in the centre, through which the apex of the finger cannot be made to pass without very great force, and an increase of all the local symptom^ Should the stricture be situated at a greater distance than four inches and* consequently beyond the reach of the finger,-happily of rare occurrencLre.' course must be had to the use of rectum bougies, or what is preferable, to the bulbous or silver ball form of this instrument, as it is less liable to become en tangled and arrested in the folds of the mucous membrane, at or about a level with the promontory of the sacrum, or the junction of the first portion of the rectum with the sigmoid flexure of the colon, opposite the left sacro-iliac symphi- sis. This examination is by no manner of means easy of performance, or satis- factory m Its results, as cases are not wanting where stricture had been supposed to exist, and treated as such, and after death no stricture has been discovered " If you employ the force necessary to make the bougie penetrate throu-h the stricture, is there no danger of its penetrating the tunics of the intesthie in- stead ? This last is no theoretical objection to the use of these long bougies in disea.es of those parts. I will not say that I have seen the patients, but I have been »«/. W on good authority, of not less than seven or eight cases in which this frightful accident occurred, and the patients died in consequence."* VIII. Symptoms op Spasmodic Stricture. This form of stricture is of rather frequent occurrence, and is more particu- lar^ seen in women. It often results from derangements of the^.-;nce vie, and IS frequently an accompaniment or symptom of h(Bmorrhoids or fissure. There IS great diLculty in defecation, attended with much straining, and pain of a sharp or spasmodic nature, during and long after the evacuation of the bowels and ,„ some cases it is ahnost constant. The passage of the finger through the phincter a&^avates the pain, but the moment it haspassed beyond it, the bowel IS found to be in its normal condition. IX. Symptoms op Malignant Stricture. ^Thisvaricty of stricture, like malignant disease in other parts of the system, •SirB. C.Brodie, Op. Git., p. 31. 18 STKICTTTRB OP THE RECTUM. generally occurs after the middle period of life, is more prone to attack the fe- male sex, and is oft«n a concomitant of disease in some remote organ. It has been observed that malignant stricture is often slow and very insidious in its pro- gress, many of its ordinary symptoms being so feebly marked, that life may be prolonged for many years. At first the patient will complain of some slight de- gree of uneasiness about the rectum and anus, and some little difiiculty in the process of defecation ; then there may be weight and pain with heat in the part; ag{un there may be scarcely any diflSoulty at stool, if the disease is of the soft, or haematoid character, and implicates but a limited portion of the bowel ; the faeces arc flattened, narrowed, and have the other appearances seen in simple stricture, if it is of the true scirrhoid form. There is a discharge of fetid bloody muco-purulent matter, almost always more or less constant, and accom- panied by increased pain, which is more of a burning, lancinating character. The pain radiates round the pelvic and lumbar regions, through the nates down to the thighs ; at this advanced period of the disease, every evacuation adds to the measure of pain which is now ahnost unremitting. There may be obstinate constipation at various stages of the disease, though the opposite condition is more likely to prevail, from the admixture of the solid feculent mass with the morbid secretions ; tympanites. Sooner or later we observe the setting-in of the characteristic symptoms of carcinomatous disease, the sallow, anxious, and unhealthy aspect of the counte- nance, so strongly portraying severe mental and bodily suffering ; there is gen- eral disturbance of the functions, and depression of the nervous power. If an examination is made, this must be borne in mind in a diagnostic point of view, there will be an increased if not a copious discharge of blood, a thing that does not occur in simple stricture, and if the disease is within reach of the finger, it will be found in different cases to present variations as to its position, form, and extent. Sometimes it presents itself under the form of a solid, hard, and incompressible tumour, implicating more or less of the intestinal canal, and having all the external characteristics of scirrhus ; at other times the stricture imparts the soft and pulpy feel of fungus hsematodes ; again, there may be a number of small tumours of variable consistency, just above the anus, and occa- sionally obliterating the canal of the intestine. X. Diagnosis of Stricture. Upon a correct diagnosis, not only of stricture, but of every other disease, is based the sole rational plan of treatment that should be adopted for its cure, and if this cannot be attained, its alleviation ; inattention to this important point STRICTUKE OF THE RECTUM. 1^ results, every day, in more or less serious errors of practice. It should be remem- bered that a patient may, at times, complain of all the symptoms usually deno- ting stneture, and yet this condition not exist, this is frequenUy seen in dyspep- tic persons ; while from more immediate causes all the symptoma maybe induced aa m pressure of a displaced or enlarged womb, ovarian, uterine, or other pelWc tumours, an enlarged prostate, and lastly abscesses in the recto-vaginal septum Again, there are several affections of the lower part of the intestine that bear a very close analogy in their general, and not a few i. -ir local, symptoms to stricture. The diseases from which it must be differenced are -.-hcemorrhoidal growths; ischio-rectal abscess; JUtula-in^no ; polypus; fissure or irritable ulcer ;s^mple infiammation of the rectum ; and for the purposes of treatment the differential diagnosis of the spasmodic and malignant forms of stricture should be borne in mind. A little attention to the symptoms of simple stricture^ already detailed-and the comparison with the most prominent mgns of the toregoing affections, cannot but lead to a correct diagnosis. a Ha^morrhoids.~There can be no possibility of error, when the hemorr- hoidal tumours are external; when, on the other hand, they are internal, the finger will readily detect near the upper border of the inner margin of the exter- na sphincter a more or less complete ring formed by soft, elastic, and compres- sible tumours, which vary at different times and under various circumstances in their size, form, colour, and consistency; they are liable to become inflamed indurated, and ulcerated, when the throbbing pain and other distressing, symp-' toms will subside, at the same time that increased purulent or sanguineous dif charges will afford temporary relief, and in some fortunate instances a permanent cure IS effected. Moreover, if the digital is corroborated by the specular exami nation, no doubt can exist as to the nature of the affection we are called upon to treat. ^ . b. Ischiorectal abscess presents itself under the forms of superficial or acute and deep-seated or chronic. ' 1. Superficial or acute abscess is generally preceded by all the symptoms of irritative fever : throbbing, shooting, darting pains through the anal and perineal regions. On examination, a hard turbercle will be felt on one side of the bowel at about Its middle portion which, increasing, will press more or less upon the' rectum, inducing constipation, sympathetic irritation of the urethra, bladder and prostate ; oedema, externally, of the subjacent tissues, and a livid spot indicltin^ the locality of the tumour, in which suppuration very early takes place rigors frequently marking the advent of this process. The pus may either be dis^harld m the bowels, or externally by the side of the anus ; this bursting of ischio-rectal abscesses is one of the most prominent causes of fistula-in-ano. These morbid 80 STRICTURE OF THE RECTUM. collections are more frequently mot with in subjects of strong and otherwise healthy conHtitutions. 2. Deep or chronic abscess comes on very insidiously and is more often met Trith in persons of weakly and lymphatic temperaments ; the pain is of a more obscure nature, and little local inconvenience is experienced unless, aa in the acute variety, it should interfere much with the functions of the neighbouring organs. The pus increasing will point more frequently towards the intestine, where there is less resistance than towards the margin of the anus ; pressure by the finger is. productive of pain, and a tumour of variable size, with a distinct fluctuatinc feel will be easily detected. If the pus — as soon as it is formed — is not evacuated either by natural or artificial means, it will burrow around the anus, throuf^h the nates and even down the thighs ; it may induce fatal peritonitis by openin<»; into the abdominal cavity through the recto-vcsical fold of the peritoneum, or less directly by the extension of the irritation. c. Fistula-in-Ano is more frequently observed in persons of sedentary habits and weakly constitution, and is, oftentimes, a symptom or accompaniment of chronic or slow disease, more particularly phthisis pulmonalis. It may be complete or in- complete. It generally results from the suppuration of haemorrhoidal tumours, abscesses caused by contusions, wounds, or the irritation of foreign bodies. There is deep-seated pain and uneasiness for some time after defecation ; an external examination will discover on one side of the anus a small ulcer surrounded by an elevated bluish red margin, and through which there is a constant discharge of reddiph fluid, at times very thin, at others thicker and partaking of the nature of pus, so that it is almost impossible for the patient to keep himself in a comfort- able or cleanly condition ; then there will be the escape of flatus, and finally of faecal matters, this last is of itself pathognomonic of complete fistula. By an in- ternal examination, the finger will detect, at a distance of from one to four inches from the anus, a small elevation on the mucous membrane — the intestinal open- ing of the fistula — and the diagnosis will be completed and assured by the passage of a probe, through the cutaneous opening, along the sinus, when it will como in direct contact with the finger. In the incomplete form of fistula-in-ano, there will be pain, heat, and a throb- bing sensation in the rectum, with some degree of hardness on the afiected side of the anus ; the dejections will be mixed with a variable quantity of puriform secretion. Pressure exerted externally near the anus — where uhe integuments according to the st!i«;e f f 1 . disease, may or may not be thinned and discol- oured — will force oirv i' t ,./ s c^: tained in the sinus ; internally, the finger meets the same appearances u'-? in i he complete form, only that finger and probe do not come together, and pain is experienced when pressure is made against the tube- rosity of the ischium and verge of the anus. STRICTURE OP THE RECTUM. 21 d. Po7j/;)Mso/Me/2ec«Mm.— la of not very frequent occurrence; happens about Iho twentieth or thirtieth year, rarely after, and occasionally before those periods • defecation becomes gradually more and more impeded; there is tenesmus and weight in the anal region ; (' o fajccs are often bloody, and occasionally present a groove or furrow upon one surface, which corresponds to the point of attach- ment, size, and situation of the polypus. When the tumor is near the anus, or its pedicle is long, it becomes extruded through expulsive efforts, when all doubt is removed ; if the polypus is retained in the bowel, the finger wiU generally Jatcct, near the anus, a smooth, movable and pediculatcd tumor ; its progress will be attended with some degree of constitutional disturbance. e. Fissure and irritable Ulcer of the Anus are, from the assemblage of their symptoms, the affections most likely to be mistaken for stricture ; as these two conditions are in almost every case present together, and are so nearly alike in their symptoms and consequences, I include them under one head. Fissure and ulcer is almost invariably situated on the posterior, or sacral sur- face of the sphincter; the situation was only found to vary in 6 out of 100 caaes; in three the fissure was on the perineal surface of the muscle, and all in women, in two on the left, and in one on the right side.* It is more commonly seen among hysterical females and those exposed to sy- philitic infection, and in enfeebled cachectic men; it may result from inattention to the regular condition of the bowels, and often accompanies a scrofulous dia- thesis, tubercular disease of the lungs, or as a sequence of chronic diarrhoea. There is very acute pain during and, for a considerable period, after every evacuation, and the pain is generally confined to one portion of the bowel, at its sacral aspect just above the anus; this pain will be occasionally complained of from the time of one evacuation to another; the fjeces wiU be streaked with blood or pus, and there is a more or less constant oozing of sanious, purulent or muco-purulent matter from the anus. The finger introduced through the anus finds much difficulty to overcome the irritability and spasmodic action of the fiphincter ; having cleared it, it will feel a depression in the mucous membraao either in the form of a small soft ulcer or, more commonly, in that of a narrow, long fissure or crack, with raised and soft edges, in one of the folds of the mucous membrane at a point corresponding generally with the coccyx. The contact of the finger increases the acuteness of the pain, and on its withdrawal it wiU be «tained with blood, marking pretty accurately not only the form and extent of the fissure, but also its situation. The constitutional symptoms are strongly marked : the countenance is expressive of great suffering; disorder of the diges- • J. RousB, British Medical Journal, May 12, 1860, p. 356. 22 STRICTURE OF THE RECTUM. tive organs; extreme nervous irritability, and all the other attendants of severe and protracted disease. The diagnosis of Fissure may be summed up in the following few words; the presence of the fissure itself, the spasmodio coptraotion of the sphincter ani, and the burning pain. f. Simple inflammation of the Rectum.— This may be induced by numerous and varied causes, many of them sitnilar to those productive of simple Stricture • there will be smart irritative fever, a „t.o intestinal strangulation, and death has occurred within • Practice of Surgery, rWladelphia, 1845, p. 434. TT > -m*. STRICTURE OF THE RECTUM. 25 two or three days. Persons have been known to die from accumulation of f^es before ulceration and its symptoms have manifested themselves, or been attended by the evidences of internal strangulation. The extent of intestinal surface involved in simple stricture varies in almost every case ; in some it may be from three to four inches in length ; in others it will form but a narrow ring scarcely half an inch, and frequently less, in thick- ness, above which the caliber of the intestine is of its normal diameter though It often forms a pouch of considerable magnitude. In some rare cases, as in one that came under my observation, that of Mrs. H., No. 3.-there was a double stricture at an interval of near two inches, the second, or highest one, not bein<. discovered till after the first one, near the anus, had been divided, when the finger being pushed through, came in contact with the second. It is very sel dom that a simple stricture forms but a partial division across the intestine though bands have been discovered stretching from one side to the other leav- mgavariable space above and below for the passage of the excretions ; these bands are sometimes torn, or they become still more strongly organized and tense from the constant pressure exerted against them by the weight of the column of fecu- lent matter from above. In stricture of the hard or scirrhous kind, a much larger extent, longitudinally as well as circularly, of the intestine is implicated spreading occasionally from the anus to the promontoiy of the sacrum ; in stric- ture caused by soft cancer, a portion only of the circumference of the bowel may be implicated, a narrowing of one of its segments from the morbid growths shooting out of the side of the intestine. XIII. Formation and development of Stricture. The proximate causes of stricture may very correctly be resolved under two heads-those arising from inflammatory action, and others, though of less fre- quency, from the cicatrization of ulcers, or of wounds accidental, or made by the Surgeon's knife. "^ In stricture from inflammation, commensurate with the causes producing it there will be an exudation of coagulable lymph, or fibrine, either on the surface' of the mucous membrane or between it and the submucous cellular tissue • this gradually assumes the appearances and characters of fibroid formations, new vessels are developed and ramify through the adventitious substance, it becomes more com- pact, or, as it is more perfectly organized, it encroaches upon the whole circum- ference of the bowel through continuity of surface, and is covered by the mucous lining of the gut, which is now very much hypertrophied if primarily afi-ected, or IS raised from the muscular coat if the disease has originated ia the submu' 26 STEICTURB OP THE RECTUM. cousceUular tissue. In simple stricture it is very seldom that the muscular coat is implicated, hence there is scarcely stricture or puckering of the three coats of the bowel, as is clearly demonstrated after the division of the mucous membrane alone. If the stricture results from the healing of an ulcer or of a wound, the con- traction takes place in relation to the cicatrization required to repair the loss and hence a proportional narrowing not only of the mucous membrane but also of the muscular and serous ooats takes place ; thus we have not only an internal ring, but an external depression from the puckering of the whole caliber of the intestine. The very few cases of spontaneous stricture spoken of can only be explained upon the assumption of some organic change in the par*, itself, from some unknown or unappreciable cause. I XIV. Pathology, In simple stricture, the mucous membrane is not only thicker but of a harder structure than natural, and is less vascular, hence its white or fibroid appearance. "InmaUgnant stricture, dissection reveals great and extensive thickening and consolidation, as well as confusion of all the parts. The disease is not confined to the coats of the intestine, but is continued more or less extensively into the collular membrane beneath the peritoneum reflected over the sacrum and bones of the pelvis. The firm, yet elastic feel, of this disease is peculiar, much resembling that of cartilage J on opening the cavity of the bowel, the canal is found nearly or completely closed the section presenting so few traces of original structure as to render it difficult to say in what particular structure the disease originates. It appears to ms to commence in the cellular membrane connecting the coats of the intestine ; an opinion not only rendered probable from the appearance of the parts, but from the evident facility with which the disease extends itself in tbe cellular tissue."* XV. TREATiMENT OP STRICTURE. I have now come to the consideration of the treatment of stricture, and it is in this part, more particularly, that I am compelled to dissent, and not without reason I believe, from the views entertained by teachers and writers and adopted by the profession at large. The only indication that presents itself is the resto- ration of the canal of the intestine to its normal dimensions, and this object can only be secured through the mechanical means now employed, or through an operation that has proved uniformlv successful in mv hands , - .' • Howraip, op. cit. p. 15. Si tl ai tl I I' - If BTRICTDRE OF THE RECTUM. 27 I will, first, speak of the treatment of simple stricture by the process of dila- tation. The first step in the operation is to pay attention to the condition of the bowels, and in some measure soothe the irritation which is constantly kept up in the rectum by the presence of a large mass of faeces pressing upon the strictured part ; the patient should be ordered light mucilaginous drinks, the food to con- sist of such articles as leave but Uttle solid residue that no further additions may be made to the already large faecal mass ; the daily use of tepid injections thrown through a long pipe heyond the stricture, and allowed to sojourn in the bowel as long as is compatible with the comfort of the patient, by which means, if properly car- ried out, the hardened faeces will become softened and diluted, ar d their evacuation, in a fluid state, U attended with much less pain and. straining than 'vi the opposite conditioH ; the patient will in some measure be relieved, and be better prepared for the second part of the treatment. This is to be attempted by the use of -r bougies, if the stricture is within reach of the finger, commencing with one that will just enter the contracted canal, and in proportion as dilatation is efi-ected, the . ^ I size of the instrument is to be slowly and gradually increased, and introduced I once m two or three days aUowing it to remain for some minutes, unless this is I counteractedbyirritationof thepaxt,which is sometimes apt to spring up in spite J of the most careful and gentle manipulation. This condition of things, when present, is to be treated by rest, the hij^bath, opium by injections or suppositories • m some cases the treatment requires to be more active, leeches and fomentation! are to be applied to the anus and perineum j and if from the extension of the irritation, there should supervene much abdominal pain with the other symptoms of peritoneal inflammation, no time should be lost to overcome it by the measures usually employed in such cases, ignoring, for the time being, the primary cause of all the trouble, the stricture. When the unfavorable symptoms have been removed, the stricture will be found pretty much in the same condition a^ . I « It was at the commencement of the treatment, and the same process must again \ { be gone over. What is the object of the bougies and will their use cure the stricture ? These . ^ two important questions are readily and satisfactorily answered in the negative by reference to those most in favour of this mode of treatment. " Dilatation seem to be the only means we possess of causing the obliteration of stricture of the rectum." * « The bougies are used for the pressure they excite upon the ring and thereby induce its removal by the process of absorption, and «o« as some have supposed by more mechinical dilatation." f Therefore absorption induced through the pressure of the bougie seem to be the only mode of cure for stricture •A. Todd, Medical Times and Gazette, August 6th, 18o9, p. 130. t R. Druitt, Principles and Practice of Modern Surgery, Philadelphia, 18l!6, p, 644. 28 STRICTURE OF THE RECTUM. I ! and this is very far from being successful, as I really do not believe it can be carried on to the degree requisite to cause the removal of the entire stricture. " Though a simple stricture may be much relieved by bougies, it is sddom I think cund by this means, there being a great tendency for it to contract as soon as the treatment is discontinued." * « WI ^n after a lengthened, persevering and annoying plan of treatment has been pursued for some time, and a considerable diameter has been obtained, dilatation becomes limited by the sensitive charac- ter of the anus, as also the irritability of the intestinal membrane, and the total absorption of the stricture is not effected." f If the above opinions are to be respected, and I know not why they .hould not, as they are those entertained more or less pointedly by all writers, is it not a little surprising that no improve- ment has been sought to be made in a plan of treatment unquestionably based upon false premises, and almost always unsuccessful in its results? HowshipJ in giving the results often of his cases treated by dilatation, says that there was but one case cured, owe partly cured; and eight relieved by the bougie. These facts seem to me to caU for stronger reasons for the exclusive use of bougies, in preference to that of the knife in the treatment of stricture, than the fear of hemorrhage, peritoneal inflammation or inflammation of the rectum ; although, singular as it may appear, these three objections are entirely overlooked in the operation for fistula-in-ano, which no one pretends to cure— even where of con- siderable extent-otherwise than by the knife, when the same parts, os in stric- ture, are more directly if not more deeply implicated. And yet, "when the ' stricture is very close, and of long standing, we shaU gain time by incinng its margin, previous to dilatation."§ « If a tight caJious stricture resists the ordinary treatment, notch slightly at several points of the contracted ring, then dilate in the ordinary way."|| " Stricture has been divided by slightly notching it at dif- ferent pointe, then use the bougie, the great risk of hemorrhage, the difficulty of checking it, and the danger of inflammation from wounds of the rectum are serious objections to the proceeding, which should only be resorted to in extreme •circumstances, and then with the utmost possible caution."^ '< If the stricture yields but slowly, is very tight and indurated, notch it towards its posterior as- pect, with a sheathed probe-pointed bistoury, without danger to the peritoneum, then a tent of coiapressed sponge for twelve hours." ** •,Eriohsen, op. cit. p. 792. tiTodd, op. cit. p. 131, t Op. cit. pp. 52-76. § Ashton, op. cit. p. 301. II Miller, op. cit. p. 426. If W. Pirrie, Principles and Practice of Surgerj, Philadelphia, 1852, p. 656. •• Erichaen, op. cit. p. 791. la i(i I STRICTUKB OP THE RECTUM £9 Other authorities to the same purpose might be adduced, but I think I have sufficiently proved that to perfect a cure, it can only be done by the use of the kmfe in the last place, when it could readily and securely have been done in the Jirst instance, and a cure effected in the course of three or four days with very little pain, and comparatively still less inconvenience to the patient ' Some strictures may have very insidiously progressed till a certain amount of contraction and hardness have ensued, and still the introduction, a few times of the bougie, and attention to the patient's general health and the soluble condition of the bowels, have determined the absorption of the effused lymph, before it had a..quired the firmness and consistence of fibroid formation. Many will no doubt, coincide in the opinion "that bougies often quickly remove' disease that at first appeared of an alarming character." * The great objection, and no doubt the most valid one, to the use of the com- mon rectum-bougie, is that, from its configuration, it not only may dilate the stric ture but It must keep the anal opening also in a proportionate stat« of dilatation and this las conaition is of itself, at times, more tedious if not more painful than the mterial portion of the treatmentt. To succeed, I will allow the expression with bougies, the rectum should be stretched to its fullest capacity, while the anus and sphincter remain in their natural contracted state. To meet this important md.cation Mr. Todd f has contrived and figured an instrument the mechanism of which IS certainly well calculated to effect the objects in view. In order to give the reader, who may not have the Gazette at band, an idea of this dilator, the following brief sketch may not be uninteresting : it consists of two blades of finely polished steel forming, when closed, a small size oval bougie. These blades are about three inches and a half long, rounded above and below, and made to separate from and approach each other in aparallel direction, by mechanism con- tained withm. Beneath these is a round stem, one quarter of an inch in thick- ness, upon which the anus and sphincter are allowed to contract. The parallel movement of the blades is effected by four slight bars of steel jlaced in pairs- one pair crossing each other above, the other bebw, united at their intersection by a pivot. The extremities of each pair, at the centre of the blades, are con- nected together and to the centre of the blades by means of hinges, their distal extremity being permitted to traverse a groove within the blades. The stem before spoken of, is hollow, and is continued above within the blades, to a fork' the extremity of which is attached to the pivot connecting the intersection of the superior cross-bars. Through this hollow stem passes a rod, which also e_n^_abov ^a fork, attached in a similar manner to the pivot through the inter- t OrSp.'S°'"' ^'''""' °" ^"'^''^' ^'^^'^^''P^^''' 1852, p. 440. 80 STRICTURE OP THE RECTUM. section of the lower cross-bars. The other extremity of the rod is a screw, on which is a graduated scale ; to this a thumb nut is fitted, having a rim upon its upper part, which revolves in a groove in the extremity of the outer or hoUow stem. With the above description of the instrument, its modus operandi h ex- plained as follows : " when the nut is turned from right to left, the inner rod is pushed up, and the intersections of the cross-bars are made to approximate, the horizontal diagonal of the central quadrangle becomes, therefore, elongated,' and thus the blades are separated. A contrary movement of the nut draws down the rod, and brings the blades together. The screw is made so fine that dilatation can be efiected by an exceedingly gradual movement." He mentions but one case in support of the use of his instrument; a lady had been two nwnths under treatment by the use of bougies, the anus only admitting one of five eighths of an inch in diameter. By cautious and gradual extension with the instrument, the stricture was dilated to one inch and one eighth with- out the least pain or uneasiness; she could retain the instrument as long as she wished, as it caused no inconvenience whatever. XVI. Treatment of Spasmodic Stricture. As already stated this form of stricture is generaly symptomatic, and, there- fore, before determining upon the plan of treatment, it is desirable, as far as pos- sible, to ascertain the causes that may have induced, and still keep up the great irri- tation and unusual contraction of the sphincter muscle. In the very great majo rity of cases this stricture will be found to be caused by a fissure or ulcer of the mucous membrane either of the anus itself, or of the intestinal membrane im- mediately continuous with it; and the only means of remedying the patient's ex cessive torture, is by dividing the aflFected part, and partially or totally through the fibres of the sphincter muscle; the after-treatment consists merely in atten- tion to the condition of the bowels, the regulation of the diet, and no tents are required. When the stricture is not dependent upon disease of the mucous membrane recourse may, possibly, be had to the use of bougies, at the same time that the proper hygienic and remedial measures are adopted ; if the stricture should resist the dilating process and the parts become very much irritated the division of the membrane and the superficial fibres of the sphincter muscle, at one or two points of Its circumference, will insure a prompt cure. Should the bougies fail, and objection is raised to the use of the knife, we may adopt ihejbrciblc dilatation recommended by Maisonneuve * b.- intrc ' ■'".' ,c • Gazette M^dicale de Paris, January, 1853. I ' i«\> STItlOTOKB OP THE EECTnM. 81 one finger, then . «K»,nd, .„J g,.d„a,|y ft, ,^ „, ^^ „ band. p„,hed through the ephincto, and *„ the n.Je i. cleared hlto gere a. t^htl, closed and the to forcihl, and euddenly withdrar tMa pt ^^ueea each an amount of relation of the .phiaeter as ,'l, effeetuaU;' ovZl^ Its ahnormal oontraotion. ■* ''™"™°'« XVII, TebaTMENT op MALIONiNT STaiOTOM. TU. fom of atrielnre is entirely beyond sutsioal aid ; pressure either by bou- of, ^t not only aggravate, the eufl-erings of the wretched patient but aM fresh sttmulua to the disease and hastens a fatal termination. There i sabll n*ng to be done but the administration of anodynes and palUaZtotl b agon„,ng pa.„., .„ ,,pp„„ ft, d«,lining strength through ,„eh mcaTst a. e.,gene,e,o any particular ease ma, call for, and to keep fte W bowel a^ free as poss,b.e of feculent matter as ha. been recommended in th "Itl^ of s.mple stneture, in one word the surgeon is a powerless specU J anT^ omce . narrowed down to smoothing the pas.^»e to the grave Im'e ° i^ ^oes not succumb undergcneral contamination of the systel a perfe'tlC J fc .ntestrne wi take place, and for which there can be no reM^^^^Z^J tos have advtsed to cutthrough the m^a. all hazard, and even withLsZl exfrpate the entire rectum, a„ operation that can never be successful aid wh' 1. rem the meagernesa of.be details and their great obscurity, onT^^;.:.;^* behevtug that the ca«s have proved fatal in a very few day^' if „ot hC Delpeeb,* unfortunately ost too early to science .,,. ,1 . i o;... is complete, it had been proposed to ::ZZoI:::::;T°''' stnctmn in order to establish a passage for the feculent mat" This !l """ oubtedly at^ed with much danger and great ineonvc ets^t cata^I t.ng mstrument through, or in the immediate neighbourhood of a ele is to hast, , the ulcerative process, which must p;veTL death oTr"'"" bat in these eaaes, let the means we adopt be wlC tb; „:! tvT; always be very defective. ^ ^' ^^^ ^^^^ Lastly life may be prolonged for a few weeks, after complete closure of th. " testme, by the operation for artificial anus in the lumbar or ilia '"' readers will necessarily understand that the chance ir I , ! 1 "'""t ""' only be entertained in cases of simple stricture. i:^Z: 2 ^:: the various surgical authorities ai, to the sitvatinn .n-1 - ^^ • Precis Elementaire, tome 3me,7^^^;ii^;;^;i;;;^ 82 STRIOTURB OP THE RECTUM. If the Stricture ia beyond the reach of the finger, and happUy this is very sel- dom the case, little hopes need be entertained from any plan of treatment, the knife cannot reach the disease and bougies more often than otherwise fail in their use. XVIII, Treatment op Stricture by- Incision. Having now described, as fully as is compatible with the limits of this dis- sertation, the history, symptoms, &c., and the ordinary pl«,. -f treating stricture of the rectum, I will conclude with a few words in relation to its treatment and cure by incision, as I have successfully practised it in six cases, and was pre- sent at a seventh, and so confident am I that this is the only correct mode of treating this afiection, that I shall adopt it in every case that may present itself in future. By reference to the surgical anatomy of the rectum, briefly sketched at the commencement of this paper, the reader can readily judge whether the objections raised against division of the stricture, are based upon the real or presumptive danger either of hemorrhage, or of wounding the peritoneum. Should it be that any thing like troublesome bleeding took place, I know not why it could not be promptly and effectually controlled by pressure, through the full distension • of the rectum, either by compressed sponge, lint, or common cotton ; should these means fail, the injection of some astringent solution will, most likely, prove beneficial ; although there are many agents of this class, the following bears the recommendation of great efficacy in arresting the bleeding after the removal of internal haemorrhoids, and would be equally applicable in that which might possibly result from the division of the stricture. Take one grain of sulphate of iron, and dissolve it in olj ounce of water, a small quantity to be injected at a time;* and, lastly the introduction of pieces of ice in the anus and rectum, as I have done in several instances after the extirpation of hsemorrhoidal growths, will effectually arrest the bleeding. I cannot but believe that undue stress has been laid upon the presumed danger of hemorrhage j and from the result of my cases, this fear has never been present in my mind, and should it in any case occur, I am confident I could control it without danger to the patient, and com- paratively little inconvenience to myself The second objection, is the wounding of the peritoneum ; by reference to the disposition of this membrane, it will be seen that there can be no possibility of implicating it in the two lower portions of the rectum, as we know that it is only in connection with a small part of the anterior surface of the middle por- tion — the most common seat of stricture — and that it is not at all to be found ^ ;-« • J. p. Vincent, Edinburgh Monthly Journal, March, 1848, p. 41. ^ -J u STRICTURE OP THE RECTUM. gg in the lower third. Between four or five and a half inches, no fears need bo entertained of wounding the membrane, even if the case is one admitting of incision, as the knife is only to bo carried through the mucous and muscular coats on their posterior surfaces, and then the serous investment can be suffici- ently dilated by pressure of the finger, precisely in the same 'Planner as it is accompliAed after the division of the ring in strangulated hernia Even ad- mitting that the peritoneum should be slightly wounded, for it cannot be much except through carelessness or ignorance, and special inflammation be the result this complication is ffenerall,, amenable to treatment, whereas none is avaUablo in stricture if it remains unrelieved, and the danger from peritoneal inflamma- tion--directly or indirectly-is almost equal, if not greater, in the treatment of simple dilatation with bougies. It is a little singular that the fear of inflamma- tion is ooked upon rather lightly after the operation for strangulated hernia, more particularly when the sac requires to be opened, sometimes to a considerable extent, and from the preceding and subsequent manipulations to return the prolapsed mass, the chances of peritoneal inflammation are increased ten-fold more than in the more simple operation of cutting through a stricture The manner in which I perform the operation is as follows :-the patient stoops forward resting his head and hands on the edge of a bed, the feet on the floor with the legs somewhat separated; in this position the nates are elevated to a convenient height for the operator; this posture I consider preferable to the recumbent one. upon the side, as there is no impediment from the bed clothes, and docs not require an assistant to keep the thighs apart. The left index finger, well oiled, is gently pushed through the anus till its apex rests on the stricture; a long, narrow, probe-pointed bistoury, held in the right hand IS carefully passed flatwise along the finger through the contracted part when Its edge IS turned a littlo to the right or left of the median line, towards the sacrum, the left finger pressing upon the back of the knife, forces it through the stricture, about the depth of the blade; the knife is then withdrawn from the stricture, turned on its side, though still retained in the intestine, while the eft finger now ascertains the nature and extent of the incision, and the stric- ture will be found to have greatly given way, and that the small wound has spread out to nearly one inch in width, should there be any undivided bands of mucous or cellular tissue between the edges of the wound, they are to be cut across, when the mucous membrane above and below the strictured part will bo f^t smooth and on a level, a similar incision is next to be made on the opposite side, and the knife removed; two finger, can now easily pass through the stric- ture in dl directions. Next introduce a piece of compressed sponge-the size ot a half dollar peice, to which a stout string is attached, and allowed to hang 84 STRICTUIIB OP THE RECTUM. out Of the anus,-in iho Btrioturo ; give tho patient an anodyne to rjuict pain and prevent tho immediate action of the bowoH and order him to bed Tho sponge i3 to bo retained, if possible, for twenty-four hours, when a brisk laxa- tive is administered, whieh will have tho effcet of expelling the sponge, and with It the contents of the largo intestines, tho evacuations aro attended with com- paratively Uttlo pain, tho patient complaining more of smarting than any thin^ else. No second dressing is required as there can be no danger, after twenty- four or thirty hours, of tho wound re-uniting by first intention ; all that is ne- cessary, is to keep tho bowels in a very relaxed condition for three or four days when tho patient may return to his ordinary avocations, cured of a very annoy- ing, and, often dangerous affection. I will now illustrate tho foregoing mode of treatment by tho notes of seven cases, in which it proved eminently suc- cessful. Case L— Stricture of the Rectum, after Ulceration; cure. One morning in February, 1850, when doing duty as Assistant Surgeon to the 4th Regt. United States Infantry, at Plattsburgh Barracks, a " loose fish " of a soldier was brought by a file of the guard to tho Hospital, complaining of severe pain in the bowels, and constipation of several days' d'lration ; as the^un- fortunate creature was an hahitui of tho Guard-house, and knowing something of his antecedents, I ordered him a dose of a most villanous mixture, composed of " picra " and the black draught, with such things as cayenne pepper and scammony for seasoning; this prescription had proved remarkably successful in clearing the Hospital of a number of idlers, and returning them very promptly to duty. In the ease of Young, the mixture was administered three times dur- ing two days, and though readily swallowed no relief was obtained ; my semeant saw particularly that the doses had been taken. On the morning of tho third day, the report was " no amendment ;" I now enquired somewhat more closely into the nature of the case, and learnt that tho man, in common with a very large number of the soldiers of the American army, had suffered very severely during the Mexican campaign, from a most inveterate and intractable form of diarrhoea, soon changing into dysentery, and which had decimated the ranks more than tho balls and bayonets of the « Greasers j" he had been for some months in hospital at Chapultepec, and was on tho invalid list on his return home. Part of his regiment was quartered at the Plattsburgh Barracks, when I was appointed to take the medical charge, and had treated quite a number of the men still suf- fering from this disease, although Young had not before fallen directly under my notice, I now thought that the poor fellow must be really ill, and, there- fore, made an examination ^cr anum, knowing full well tho different tricks STRICTURE OP THE RECTUM. 8ft m soldiers will bo up to, in order cither to fihirk duty, if not to procure their dis- charge from the Bcrvico. I was not a little surprised to find, that though the fin- gor passed with some difficulty through the anus, it soon-at the distance of about three inchcs-camo in contact with a tight resisting ring, through which I could not push the point of the finger. The case had now resolved itself to one of stricture, from tho healing of one or more ulcers resulting from chronic diarrhoea. Looking over tho surgical appliances of tho Hospital, I found nothing in the' shape of rectum bougies, and unable to wait a requisition upon the medical purveyor, I saw myself compelled to follow a plan of treatment diflferent from that laid down in the books, and aa tho man was cvidenUy faUing, I did not hesitate to perform the foUowing operation :-Placing him in a stooping position, his head and hands resting on his bunk, I introduced tho left index finger, well oiled, into the rectum up to the stricture, and then carefully passed flatwise a probe-pointed bistoury; this was pushed through tho ring of the stricture, and a cut made to tho left of tho median Une, towards tho sacrum, the finger now ascertained that the strietured part had been completely divided through, without implicating anything else than the mucous and a portion of tho muscular coat, as tho evenness of the lining membrane, on either side of the stricture plainly indicated ; the finger could readily bo passed through tho divided stricture, and a litUe pressure imparted the sensation of tearing, or giving way, just as is experienced in tho operation of hernia. However, fearing that through some means re-union might pc3sibly take place, and the stricture be closer than ever, I made a similar cut upon the opposite side, when the knife was withdrawn, and two fingers could easily be introduced in the bowel without force, and very little pain. There was not a teaspoonful of blood lost; a piece of compressed sponge, secured by a thread, was pushed into the stricture, an anodyne administered, and the patient ordered to bed. The following morning a large dose of castor oil was ordered, the sponge and an immense quantity of faoces were discharged, and in four days, he was re- ported fit for duty. He continued in the service tiU the expiration of his enlist- ment-two years— and never had a return of his old complaint. I look upon this case as one of perfect cure; and the plan of treatment adopted suggested itself from the want of the ordinary instruments usually recommended in such cases. CasellStricture of the Rectum complicated with ItcmwrrUids ; cure. January 10, 1853, J. Sampson, of Alburgh, Vermont, requested my advice for hajmorrhoids that had, at times, during two years, troubled him very m'uch j at that period he began to complain of more or less pain when at stool, had consulted 86 STRICTURE OP THE RECTUM. ,1 I V some physicians, and takca any r entity of patent pills for the purpose of regu- lating the bowels, but all to no purpose, when small tumors were protruded after every evacuation with great straining and increase of all the symptoms. Being now fully satisfied that he was suffering from piles, he resigned himself to his fate, under the impression that there could be no cure. It was under these circum- stances that he called at my surgery in relation to a daughter who had been for some months in ill-health, and incidentally alluded to his own case; answers followed questions, and an examination proposed to which he immediately acceded, being perfectly willing to submit to anything that might offer the least prospect,' ^f not of cure, at least of relief. There were two or three small hajmorrhoidal tumours around the verge of the anus, and the finger could only be made to pass through the external sphincter with some difficulty, when, within two inches above it, I detected the existence of a stricture. The case was now plain, and I told the patient that the chances of cure were decidedly in his favour, and that all the suffering arose more probably from the stricture than from the piles. Ho readily acquiesced to all I proposed; and the operation was performed the follow- ing day. In the same manner and with the same after-treatment as in the first case. He returned home on the third day, the bowels having been freely and copiously emptied by strong laxatives. In two months he reported himself free from trouble in the process of defecation, and rid of his old complaint the piles, the one operation had cured both. Four years after he wa.s still in the enjoy- ment of perfect health. This case is rather interesting, as no doubt the development and gradual increase of the stricture, prevented the free return of the blood, and consequently favoring the engorgement of the haemorrhoidal veins, was the direct cause of the hajmorrhoids themselves, as they immediately began to decrease the moment the stricture had been divided and consequently the pressure removed. Since the occurrence of this case, when consulted for hjemorrhoidal affections, particularly where the symptoms are well marked, I generally call for an examination, being convinced that stricture may occasionaly not only be complicated with hEcmorrhoids'i but that it may, in some cases, be the direct cause of their development. Case III— Double Stricture of the Rectum mistahcn and treated/or disease of the womb; cure. Mrs. H. of Champlain, New York, thirty-seven years of age, the mother of three children, the youngest nine years old, had been in bad health for some time past, when she called upon me in Nov. 1853. She was of a fine/^«,r, and of very sedentary habits; near three years before, she remarked an unusual si 1 ie I V ^? STRICTDIIE OP THE RECTUM. 37 degree of straining at stool, with some trifling pain, though she was not generally inclined to costiveness ; thepain and straining kept gradually increasing till they had become almost unbearable, and she was rather pleased than otherwise that the bowels were costive, as she seldom had more than one or two calls to the co„!7T, .TV'"''"'- She complained of pain in the back and thighs ; considerable difficulty in micturition, and a more or less constant bearin. down sensauon, aggravated at, and immediately after, an evacuation; the menstrual function wa. normal as to time and quantity; occasional slight leucorrh<.al dis- cha ge, and some pain during sexual congress. She had tried various plans of treatmen without any amendment, and considered herself, as she had been to'd by a medical man-however Mont an examination-labouring under some disease of the womb, for which she had submitted to empirical and other treat- ment. Having become acquainted with the foregoing particulars, I proposed a vaginal examination to which she consented after a little hesitation ; I found nothing a normal either in the vaginaor in the positionand configuration of the womb ; although I distinctly felt some hardness of the recto-vaginal septum, like ortion hardenedf^ces retained in the rectum. I next made arectal e;am! n ion, and at once discovered the cause of the mischief in the shape of a stric- Irtain .7" 7 '''""' ''^'^ "'*"" ^''^^ ^""^^"*' -^ «*-"S l^opes en- tertamed of a perfect cure. The operation was performed a few days after ; and the finger having been pushed through the stricture to ascertain if every thing Z t";T/" '"*"'' '^"* '"^ "^'^ ^''''''' ^^*^ ^ --"-J stricture, which was also divided, sponge dressing, &c., and she returned home on the fiflh day. I had the pleasure of seeing this lady several times afterwards, and she had never mpl^ned either of trouble in the womb, or when attending to the evacuati" P atM w M "" ""' '"' "''' " '''' "''"^'^ '' ^^^y- 1858, when I left Plattsburgh for Montreal. There are many important points connected with the foregoing case-the con- sideration of which I cannot now enter upon-more particularly the sympathe- icirritation of thewomb which had been looked upon as the principal disease, and treated, necessarily, without success. Case IV.-^Stncturc of the Rectum and fistula-in-ano in a phthisical suhject; aire of the stricture. Mr. H. Chatterton, of Bcekmantown, New York, aged about 40 years, a strong stout man, though of a confirmed phthisical habit, consulted mo in the fall of 1862 for a fistulous opening near the anus, from which he had suffered, morp .r i033, aunng iour years; pain in defecation, disturbed action of the bowels and 88 STRICTURE OF THE REOTOM. latterly derangement of the digestive organs, etc. ; there had always been a dis- charge from the opening, so profuse, at times, that he could not keep himself in a cleanly or comfortable condition. On examination I saw a large, wide external opening to the left of the anus; the finger being pressed up the rectum came, at about three inches, in contact with a very tight stricture ; about one quarter of an inch below it, was the inner opening of the fistula, and this diagnosis was corroborated by the passage of a probe. I now told my patient that his suffer- ings resulted more from the stricture than from the fistula which, although trou- blesome and annoying, was of benefit to him on account of his lung -affection. He readily acquiesced in my decision, and the operation was performed. In one week he was discharged, when he wished me to operate for the fistula which I peremptorily refused to do. He died some nine months after of phthisis, but I could not obtain permission to examine the body. It may, to the junior practitioner, appear rather singular that after having succeeded so well with the stricture, I would not undertake the more simple operation for the cure of the fistula ; this I could not do, and sur-ical or any other kind of interference would not only not have cured the local disease, but would have hastened the full development of the tubercular affection. Upon this point I will quote the following extracts, the first from Sir Astley Cooper and the second from Sir Benjamin C. Brodie ;— " The surgeon often brings dis- credit upon himself by operating for fistula-in-ano, in the last stage of phthisis, and when it is impossible that the disease can bo cured, therefore that death which is the result of the pulmonary disease is falsely attributed to ih.(i fistula- irirano" " In those cases in which a fistula-in-ano occurs in connection with some or- ganic disease of the lungs or liver, I advise you never to undertake the cure of the fistula. No good can arise from an operation under these circumstances ; but if you perform it, one of two things will happen— either the sinus, although laid open, will never heal ; or, otherwise, it wiU heal as usual, and the visceral disease wiU make more rapid progress afterwards, and the patient will die sooner than he would have done if he had not fallen into your hands." rt Case v.— Simple Stricture of the Rectum; cure. M. J., Esq., surgeon dentist of this city, a gentleman of high mental acquire- ments and good sound judgment, consulted mo in the summer of 1859, for a long standing trouble about the anus. The bowels were always costive, and their motions attended with such increasing and acute sufferings, that for months he had delayed aa long as possible attending to the calk of nature, and latterly STRICTURE OP THE RECTUM. 39 had only bcon able to secure anything like a bearable evacuation through the means of repeated injections, for the purpose of diluting the faces. He had been under the care of some of the medical men of this city, who had recom- mended various drastic and laxative preparations to overcome the costive habit and to remove the supposed irritability of the rectum and anus, had employed suppositories of opium and belladonna. All these measures were, however, of no avail, and the disease was constantly increasing, when discouraged and almost wea- ried of a suffering existence, and thinking something might be <-C°ovm . ^ 3g , operation for, a cause of Stricture, n , case of, complicating Simple Stricture 31^ Formation and development of Stricture, Frequency of Stricture, — — , AsHTON on the, , BcsHB on the, jq, , Nblson on the, j^^ History of Stricture, - BemorrhRge, feafs of, in incisinga Stricture, 32 , sources -whence it may come from 9 Haemorrhoids, case of Stricture, complicated with, 35 , diagnosis of, j^ HowsHip, on the Pathology of Malignant Stricture, 26 , operations on the rectum not productive of Stricture, 12 , results of cases treated. by dilatation, 82 Incision, treatment of Stricture by 32 , mode of performing the operation by, 33 Inflammation of the Rectum, diagnosis of simple. 22 Injections, improper use of, a cause of Stricture, Ij Malignant Stricture, diagnosis of, 22 ■ , symptoms of, i ■ , Spasmodic 3„ , varieties of, " , from simple inflammation of tlie Rectum „- , . ' 25 , irom cicatrization of ulcerations, „« ' •••• ^g , case of from, , ' 34 ' —Of double, mistaken for disease of the womb, ^6 I complicated with fistula-in-ano, . . : 31, """"' I — — haem6rrhoid3, 35 , cases of simple organic, 11 '->'a .» lODD s dilator description and use of, » on the use of the bougie, Ulceration a cause of Stricture, , case of Stricture from, Varieties ofStricture ' 13 ViNCKNT, on astringent injections in hemorrhage from the Rectum, 32 Whitr on the seats of Stricture, Womb, disease of the, mistaken for Stricture « ' 08 If .. 32 .. 30 .. 13 . 25 . 26 . 34 . 36 . 37 . 35 59, 40 • 29 ■ 28 . 12 34 13 33 15 36 If \.-"