The existence of stricture is in general readily ascertained by examination with the finger; its most common situation is here shown; the medical practitioner must not suppose that every obstruction, however slight, to the passage of a bougie into the bowel is owing to organic disease; the top of the sacrum naturally projecting forwards on the commencement of the rectum, in some degree opposes the entrance of any large body, and this circumstance is laid hold of by the unprincipled or ignorant; the patient is very often declared to labour under stricture of the bowel, when none exists. Some practitioners discover stricture in almost every patient with disordered digestion; the whole digestive apparatus is certainly thrown into disorder by obstruction in the lower part, but this obstruction is fortunately rare. In cases of tight stricture, the bowels are distended with feces and flatus; and if evacuation is not procured vomiting ensues, followed by enteritic symptoms, as in strangulation of the higher bowels. The gut above the stricture is always more or less dilated.
The symptoms which lead the surgeon to suspect the existence of stricture, are—difficulty in voiding the excrements; a long time occupied in the evacuation, with pain and much straining; small thin portions of feculent matter coming away, when the matter is consistent; discharge of puriform fluid, mixed with a slimy mucus; itching and heat in the parts; and irritability of the urinary organs.
Strictures of the urethra and rectum often coexist, as exemplified by the following case:—A middle-aged man, when in Holland, laboured under a very deep and extensive fistula in ano. Sinuses were divided in all directions, and some healed; one, however, remained open, leading towards the gut from near the tuberosity of the ischium on the left side. He was desired to keep this open by means of bougies, which, as many were used, he manufactured himself out of cloth and plaster. On one occasion a portion passed deeply, and could not be extracted; but his alarm at this occurrence was appeased on being told that the foreign body would be absorbed. His condition at that time was very miserable; and inflammation was often excited in the parts, with fresh collections of matter. At the same time, he laboured under stricture of the rectum and urethra. He applied to me fifteen years after the commencement of the disease. Then the most troublesome symptom was a constant itching in the perineum, and round the anus, preventing sleep, and causing much excoriation from involuntary scratching; besides, he was annoyed by seminal emissions, and frequent desire to make water. I first divided a small internal fistula, and some time afterwards operated on a large complete one; in the latter instance, a foreign body was felt deep in the wound, the incision was extended, and a large portion of bougie, firmly impacted, was with some difficulty withdrawn. Some days after, other portions of bougie were extracted along with numerous hairs; and these continued to be discharged for many weeks. The symptoms were much relieved. An occasional itching remained, but disappeared after the cure of a very bad stricture in the urethra. He recovered perfectly from the complication of diseases.
Schirro-contracted Rectum, a malignant and truly horrible disease, may be the consequence of inflammatory action, or of neglected stricture. The neighbouring parts are involved in cartilaginous induration; the surface of the bowel is lobulated and ulcerated, its cavity is contracted, and the discharge is profuse, sanious, bloody, and putrid; there is frequent desire to void the contents of the gut, but in general nothing but flatus and puriform fluid is evacuated; when feces do pass, dreadful pain is excited, and continues for some time. The difficulty of voiding feculent matter becomes greater and greater, frequent attacks of ileus occur, and in one of them the patient expires. During the progress of the disease, the functions of the bladder become disturbed; change of structure in it and in the vagina takes place; and frequently the cavities of the rectum, bladder, and vagina are laid into one by inveterate and malignant ulceration. The affection is more common in females than in males, and rarely occurs in young persons. The countenance has the sallow hue peculiar to carcinoma, and in the advanced form of the disease becomes still more cadaverous from profuse discharge of matter and frequent hemorrhage.
The cellular tissue, anterior to the rectum, is liable to become the seat of tumour. Malignant medullary formations occasionally form here, causing most distressing symptoms; by displacing the bowel they may obstruct its canal, and simulate stricture or schirro-contraction.
Prolapsus Ani. Folds of the lining membrane of the lower portion of the rectum are apt to protrude during evacuation, as already mentioned, in those labouring under hemorrhoids. These are readily replaced, and the painful feelings relieved, if the attempt be made before swelling and engorgement of the vessels and cellular tissue take place. Protrusion, however, is sometimes to a great extent; the sphincter is relaxed, and the lower part of the bowel is retained within it with difficulty; indeed there is often more of the lining membrane of the gut without the sphincter than within it. The mucous lining becomes insensible, thickened, and white; and the patient is subject to attacks of inflammation, with additional swelling, excoriations, and ulcers of the parts. Slight protrusion is very common, and patients who have long laboured under it are in the habit of reducing the bowel after every stool, in the intervals wearing a supporting bandage. They are subject, however, to constant uneasiness, and more or less puriform discharge from the parts; often there is a flow of blood while at stool; the health is undermined, and comfort diminished; all exertions are gone through with difficulty, and undertaken with reluctance. During exertion protrusion is almost certain to occur, and apt to be increased. The part most commonly prolapsed in time becomes hard, thick, and in a measure insensible; and new folds appear on extraordinary straining at stool, in coughing, or any exertion of the abdominal muscles.
Tumours occasionally grow from the coats of the rectum, and are of various consistence. They may be either vascular, or deposited in consequence of increased vascular action, and afterwards increased by addition of solid matter. They are to be removed either by ligature or incision, according to their situation, nature, and attachments.