CHAPTER XV. STRICTURE OF THE RECTUM. WHEN we consider the many points of analogy in structure and function of the rectum and those of the œsophagus and urethra, and of the numerous sources of irritation to which the terminal portion of the intestinal tube is exposed, it is not surprising that, like the lastnamed two mucous canals, it also should be liable to the formation of stricture. Contraction of the rectum is met with under two very different forms. The one consists of a contraction and induration of its coats and deposit of lymph in the connecting cellular tissue, which, when occurring within certain limits of the anus, and coming under our observation before it has proceeded to too great an extent, is very amenable to judicious surgical treatment. But in the other form, unfortunately, we are able to do but little more than palliate the sufferings of the patient, and perhaps retard the onward progress of the disease to a fatal end. This second kind of contraction consists of those heterologous growths and degeneration of struc ture denominated malignant, appearing as carcinoma, encephaloid, or colloid disease. It is obviously highly essential we should consider the two forms separately, and not confound them together; for, as Mr. Syme* remarks, "Want of attention to this very obvious and necessary distinction has led to great misapprehension in regard to the nature of the disease, and serious errors of practice in its treatment." In this chapter it is intended to consider only the simple or benign stric ture. Stricture of the rectum results from inflammation and prolonged irritation produced by a variety of causes, and, as a consequence, the deposit of plastic matter interstitially in the proper tunics and intercellular membrane of the intestine, by which degeneration and alteration of the tissues are induced; the capacity of the bowel is diminished, and is still further decreased by the property of contraction inherent in the effused material. Constipation, however induced, is one of the most frequent causes of irritation in the lower bowel, the fæces lodge in the sacculi of the colon, become hard, accumulate in the rectum, and set up a chronic state of low inflammation. Prolonged indigestion, depending on functional disorder of the stomach, duodenum, pancreas, or liver, may have the same effect, in consequence of the acrid * Op. cit., third edit., p. 107. ness and irritating properties of the excrementitious matter; and there are very few who have not themselves, when suffering from temporary derangement of the digestive organs, experienced, during defecation, the acute scalding and irritation so frequently attending that condition. Another frequent source of irritation is the very general habit, among many individuals, of having recourse improperly and too frequently to powerful and drastic purgatives. Dysentery and diarrhoea, particularly when neglected or improperly treated, will lead to the formation of stricture, and it may also result from the cicatrization of ulcers attending the former disease. Stricture of the rectum is also caused by a deposit of fat or fibrous tissue exterior to the bowel, but more frequently the coats of the intestine will be found infiltrated with the morbid growth. A case is recorded by Mr. Travers* of an excessive growth of fat external to the tunics of the rectum causing contraction. I have in my possession a specimen of stricture of the rectum, from a deposit of fibrous tissue external to its coats; it occurred in a woman, aged fifty-four, who had been ailing for twenty years, and for the last three years had been subject to relaxed bowels, occasionally passing blood. Ten days previous to death she was seized with severe pain in the abdomen, which subsided in a few hours. After this constipation followed, and on the eighth day * Medico-Chirurgical Transactions,' vol. xvii, p. 361. she took some castor oil; vomiting supervened, with great distension of the abdomen and considerable pain; no evacuation of the bowels was obtained. On the following day she was admitted into a public infirmary. She was much exhausted, and complained of great pain in the abdomen, which was large and tympanitic. The previous history of the case indicating disease of the rectum, an examination was made, and a contraction of the bowel found to exist at three inches from the anus, surrounded by a dense mass of morbid structure. She died, the day after her admission, from exhaustion. On post-mortem examination, the intestines were found greatly distended. No peritoneal inflammation existed. The rectum was contracted at the part already mentioned, and was surrounded by a large mass, having the appearance of fat, and very dense; but by the aid of the microscope, as well as subjecting the specimen to the action of ether, it was found to be composed of fibrous tissue alone.* Injuries by foreign bodies, or from attempts to extract them; lacerations of the mucous membrane, or of the whole thickness of the intestinal walls, also produce stricture; in the latter case it is usually very intractable, as is urethral stricture, the result of laceration by external violence; operations for fistula in ano and the extirpation of hæmorrhoids, when improperly performed, have given rise to this affection. Authors also * See also 'Pathological Transactions,' vol. vi, p. 201. mention syphilis, metastasis of cutaneous eruptions, and suppression of discharges that have existed for some time, and have become habitual, as causes of stricture of the rectum. Others are of opinion that there is frequently a predisposition to contraction of the rectum; and one recent author thinks this is not only the case, but asserts he has "repeatedly noticed several members of the same family afflicted with stricture.” It must not be supposed, as some writers would lead us to do, that stricture of the rectum is a very frequent disease; those who have had the greatest opportunities and the most extended fields for observation, whose acumen in the diagnosis of disease, and whose integrity is most to be relied on, have not met with this affection In the museums of our as a common occurrence. hospitals the pathological specimens are few, and those who are in the habit of seeing large numbers of postmortem examinations meet with examples of it but seldom. In a large parochial infirmary in which I have had opportunities of examining many bodies, I have seldom discovered stricture of the rectum. In public and private practice I have met with not a few cases of dyspepsia in which the symptoms simulated those of stricture, and, had I been induced to have used bougies at the same time that internal remedies were prescribed, I might have deluded myself with the belief that I had cured a disease which, in reality, had never existed; however, |