On the introduction of the finger I found about one-inch and a half from the anus, an annular stricture which almost entirely occluded the bowel, with ulceration and gummata below. More close inquiry elicited the fact that the stools were not much larger in circumference than a lead pencil. He had noticed the trouble not more than two months before. There was a previous history of chancroid at the age of 19, with no constitutional symptoms.
It is claimed that organic stricture does occur without previous ulceration by interstitial deposit and thickening, and ulceration follow. But this must be considered exceptional. The ulcerative process usually precedes, and through efforts at repair, cicatricial bands are thrown out, producing a narrowing and contraction of the canal, either in places or throughout the circumference of the bowel.
Fig. 18.—Rectal Bougies.
Electrolysis may be tried for the relief of stricture before resorting to the usual methods of breaking up by forced dilitation. If divulsion be decided upon it should be complete at one operation. Should the fibrous bands be strong and unyielding, nicking the edges with a probe pointed bistoury is advantageous.
On account of severe hemorrhage and other untoward symptoms likely to follow a complete division of the stricture, the galvano-cautery is decidedly preferable to the common proctotomy knife. A duplicature of the peritoneum coming down to within about three and a half inches of the anus anteriorly, should not be lost sight of in operations on the rectum. The persistent use of bougies will be necessary for a long time after divulsion.
Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated by Allingham, ten of the number were found in men and sixty in women, showing a great predominence in the latter; and none were more than three and a half inches above the rectal orifice.
It is not an easy matter to diagnose between the advanced stages of non-malignant rectal ulcer and cancer. Both may be accompanied by tender, condylomatous growths or flaps of skin outside the anus, bathed with an ichorous fluid. The characteristic, unremitting pain of cancer may be absent in its formative stage, and in this respect insidious in its approach, the same as the non-malignant ulcer.
Allingham speaks of a very rare species of rectal ulcer, which he terms rodent or lupoid, that is superficial, does not implicate the surrounding parts, devoid of hard edges or surface, very painful and only cured by complete extirpation.