A system of practical medicine. By American authors. Vol. 2

by Unknown

Non-malignant Stricture of the Rectum.

In the absence of ulceration or syphilitic infection this is an uncommon disease, and very many of the cases of so-called stricture of the rectum are caused by spasm which always disappears during anæsthesia.

The affection may be described as a narrowing of the lumen of the rectum, more or less circumscribed, by the deposition of inflammatory lymph or fibrous tissue in the mucous, submucous, or muscular tunic of the bowel. It may be due to traumatic causes, such as the introduction of foreign bodies, the frequent and careless use of enema-pipes, or the presence of sharp or irritating substances swallowed, as pieces of shell or bone. It is said to have been caused by indurated feces, but no cases have been published in which this causation is clearly shown. This condition has also been brought about by various operations upon the mucous coat of the bowel, such as the application of nitric acid and other escharotics and the removal of portions of mucous membrane and of hemorrhoids.

Stricture may be secondary and a result of extension of an inflammation outside the bowel, as pelvic cellulitis; and it is frequently caused by syphilitic deposition and by chancroidal invasion—in the former by infiltration, ulceration, and cicatrization, in the latter by unnatural sexual connection, or by infecting vaginal discharge running into the bowel.

When the stricture involves only the mucous tunic, it imparts to the finger the sensation of a ring-like elevation or a valve-like projection, into which the finger enters or beyond which it passes usually without much difficulty; but when it involves the submucous and muscular layers, as after the cicatrization of a large rectal ulcer, the finger encounters a dense fibrous mass which in some cases appears to have no lumen, but in others will admit only the end of the finger. In these grave cases of long standing there occurs considerable dilatation of the rectum above the stricture due to fecal detention and impaction at this point, and hypertrophy of the muscular coat of the bowel produced by long-continued straining and expulsive efforts.

Allingham² speaks of chronic constipation as a cause, and says, "Straining to evacuate the contents of the bowel forces down the upper part of the rectum into the lower, causing an intussusception; it gets within the grasp of the sphincter muscles, and this may be the starting-point of the irritation." Stricture does not usually follow proctitis, even when the latter is very chronic. The long-continued pressure of the child's head in cases of delayed labor is said to have caused stricture of the rectum.

² Diseases of the Rectum, p. 195.

This affection is a disease of adult life, and more cases of it occur among women than among men. "If stricture of the rectum is found in a young woman, it is probably due to chancre cicatrices; if it is met with in old women and men, the inference should be that it is either caused by cancer or by syphilitic infiltration and its consequences. Only in those cases in which no cicatricial tissue has been formed—that is, when the contraction is due to the infiltration alone—will the results of the antisyphilitic treatment contribute anything toward rendering the diagnosis more certain."

Stricture of the bowel may exist for months and years without being recognized and without causing the patient much uneasiness; more frequently, however, there is marked uneasiness, with an increased desire to go to stool and a sense of weight or of a foreign body in the bowel. Violent straining accompanies the act. It is given usually as one of the most common and reliable symptoms of this condition that the feces are flattened, ribbon-shaped, or triangular or wire-drawn: in true stricture, according to Allingham, this is not the case, but the characteristic stool consists of small, irregular, broken fecal fragments. When the contents of the bowel happen to be watery, the loose stool is spurted out with great force. In this disease diarrhoea alternates with constipation; the intestines become distended with quantities of gas and feces, which provoke frequent and severe attacks of colic; the appetite and digestion fail; the complexion becomes sallow; the patient emaciates; ulceration sets in, and the patient slowly sinks from exhaustion. Usually, these cases do not give rise to much pain, and what there is, is usually referred to the back, thighs, penis, or perineum. A discharge of mucus resembling white of egg immediately precedes each action of the bowels. Usually, these strictures are within two and a half or three inches of the anus, but sometimes they have been found high up in the sigmoid flexure, and rarely at a greater distance. A syphilitic stricture by direct inoculation is found just within the sphincter muscle, and consists of an infiltration of inflammatory lymph in a circumscribed portion of the submucous tissue. It is tight, highly sensitive, thickened, inflamed, and bathed in pus; there are also constitutional symptoms, as fever, anorexia, and mental irritability. The subjects of this variety are usually women. The tissues composing strictures of the rectum of a very chronic character are found to be gray or bluish-white in color, of very dense fibrous structure, and creaking under the knife when cut, as a piece of cork would do.

Besides the before-mentioned stricture, due to the contraction of a chancroidal ulcer, is another caused by submucous gummata of the ano-rectal region, which is very rare; and yet another, the diffuse gumma, or ano-syphiloma of Fournier, which is the most frequent of all causes of stricture of the rectum. The diffuse gumma is one of the later manifestations of syphilis, and consists in "an infiltration of the ano-rectal walls by a neoplasm of as yet undetermined structure originally, but susceptible of degenerating into a retractile fibrous tissue, and thus giving rise to narrowing of the intestinal calibre to a greater or less extent."