sometimes makes frequent partially successful attempts daily at
defecation, but may experience an unrequited desire for stool. The
patient acquires the reprehensible physic-habit. In time the periods
of obstipation are interrupted by diarrhea. There is an ineffectual
straining at stool except for fluid feces. Later the diarrhea occurs
with greater frequency, and ultimately long periods of diarrhea
may ensue which are interrupted by a transitory constipation and
obstipation. All these symptoms may be accompanied by increasing
degrees of flatulence and borborygmus, and from time to time the
patient is subjected to attacks of intestinal autointoxication,
and finally he becomes neurasthenic. On account of the especial
nonsensitiveness of the rectal valve the patient’s sufferings are not
uniformly referred to this region by himself, but in many instances,
however, the intelligent patient is prepared to present his physician
with a ready-made diagnosis of rectal obstruction. Finally, the
symptoms of intestinal obstruction become pronounced, and if the
patient be unrelieved the disease proceeds to a fatal termination.
Symptoms of pain, aching in the sacral and iliac regions, hemorrhage,
proctorrhea, prolapse, hemorrhoids, fistulas, etc., are usually the
signs of concomitant sequels of the hypertrophied valve, and these may
embrace the entire proctica. For a classic graphic description of the
symptoms of rectal stricture, which has never been excelled, the reader
is referred to the paper by Dr. Sherwin published in the Transactions
of the London County Medical Society in 1787.
PATHOGENESIS.
1. _Obstructive anatomic coarctation_ of the normal rectal valves is
a fortuitous embryonic affair, and admits of no amplification in this
section.
2. _Prenatal hyperplasia_: The fibrous and muscular laminas of the
rectal valve are developed from the mesoblastic layer of the blastoderm
and the mucous membrane is derived from the hypoblast; this latter
layer consists of columnar epithelium, and epithelium of this character
may be found covering both superior and inferior surfaces of congenital
diaphragmatic strictures or membranous septums. When there exists an
aperture in this character of stricture it is seldom or never situated
centrally. Another distinguishing feature of this obstruction is
that it constitutes a cephalad boundary to a rectal chamber. If the
lowermost valve be deformed, and if it be situated unusually low down,
the lower rectal chamber may be noninflatable. In such an instance
the anal or fixed rectum may seem to be of an extraordinary length,
but that such is not really the fact may be determined by digitally
ascertaining the situation of the anal borders of the levatores ani
muscles. Such a stricture has its origin, probably, in the embryonic
hyperplasia of the rectal valve. Another form of diaphragmatic
stricture is sometimes observed at the anus. It has its origin in an
imperfect anorectal coalescence. The salient structures of this septum
are hypoblastic enteron and epiblastic proctodeum, and a microscopic
inspection of a portion of membrane taken from its inferior surface
reveals its epiblastic origin. This anorectal septum is of variable
thickness, if there be a perforation it is located centrally. This
character of stricture is always situated caudal to the rectal
chamber. It is due to an arrest of fetal development.
3. _Postnatal hypertrophy_: Inflammation of the normally formed rectal
valve, infiltration of lymph through its structures and organization
of the plastic exudate contract and fix in a state of contraction
this normal projection across the lumen of the rectum and constitute
the nonmalignant annular stricture of this organ. Abnormal increase
of fibrous tissue from any cause may, without contracting the
valve-strait, render the valve sufficiently inelastic as to constitute
it an obstruction. Extension of the inflammatory processes to an
adjacent valve or a general hypertrophic rectitis involving an area
occupied by several valves, consequent contraction of the longitudinal
muscular bands in the area involved, together with contraction of
the circular muscular bands, the infolding of masses of the lax
mucous membrane, and the infiltration of plastic lymph into all these
tissues between the valves as well as into the valve structure itself,
organization of the exudate, degeneration of the muscular elements
and increase of fibrous tissue, is the probable sequence of morbid
processes which establish the nonmalignant tubular stricture of the
rectum. The great thickness of the gut-wall at the situation of the
tubular stricture is ordinarily not a new product of the disease. It
is the consequence of the infolding of the mucous membrane, fixed in
longitudinal corrugations by the organization of the plastic exudate.
The causation of hypertrophy of the rectal valve may be direct
infection; a rectitis, dysentery, chancre, chancroid, gonorrhea; or
traumatism, irritation or injury by a foreign body; the irritation of
scybalums; or, it may be the local expression of some constitutional
dyscrasia; syphilis or tuberculosis. The influence of age or of
emaciation, through atrophy of the cellular tissues and the hypertrophy
of the fibrous, may contribute a relative increase to the tendinous
feature of the rectal valve.
_Because of the absence of the rectal valve in the rabbit, cat, dog
and monkey_ it was found impossible to do vivisection work for the
production of an experimental stricture.
There are many specimens of hypertrophied rectal valves to be seen
in the metropolitan museums in Europe, none of which, of course, are
classified as such. The cases quoted below were copied by me from the
catalog of the Pathological Museum of the Royal College of Surgeons,
London, and the specimens which are pictured here may be found on
their shelves. These cases are chosen for illustration because their
accessibility affords the reader an opportunity for their verification.
The pictures were drawn under my direction by Mr. Godart with the aim
of illustrating this essay. The specimens immersed in preservative
are sealed in cylindric glass jars of the usual laboratory type.
Each of these we set into rectangular vessels of water to overcome
refraction-errors and afford accurate appearances.
The first case quoted is one of traumatic injury to the rectal valve,
and, I believe, affords a close imitation of what might have been
expected from an effort at the production of an experimental stricture
by simple inflammation of the rectal valve.
The method used for the preparation and preservation of these specimens
accounts for the nonappearance of the normal valves. From the time of
the preparation of Hunter’s first specimen to the present time more
than a century and a quarter has about elapsed.
[Illustration: FIG. 55.--Drawing of specimen No. 2569 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 55. “Specimen 2569. Presented by William Coulson, Esq. A rectum
and part of a colon, the blood-vessels of which have been minutely
injected. Six inches above the margin of the anus there is a very close
and narrow annular stricture of the rectum, produced by thickening and
contraction of its coats and of the tissues immediately surrounding
them. The inner surface of the stricture is ulcerated, and a small thin
piece of fish bone is sticking in it. Above the stricture the intestine
is dilated to a diameter of nearly four inches, but its coats are not
much thickened.” The following is the history of the case:
“‘I was requested to see a woman, aged 34, between four and five months
advanced in pregnancy, who, three days before, had been seized with
sickness, constipation, pain, and distention of the abdomen. These
symptoms increased in severity, fecal matter was rejected from the
stomach, the abdomen became more distended, no evacuation could be
obtained from the bowels, and the injections which were attempted to be
thrown up the rectum were immediately expelled. Her powers gradually
sank, and on the third day from the commencement of the attack she died.
“‘On examination after death, the colon was seen to be exceedingly
distended, especially its descending portion, and about six inches from
the anus a foreign body, believed to be a small portion of fish bone,
was found adherent to the lining membrane of the rectum.... Immediately
below this body the bowel was completely closed, to the extent of half
an inch, by the effusion of lymph caused by the presence of the foreign
substance. There was no other morbid appearance.
“‘Prior to the attack which destroyed this patient, she was in her
usual state of health and had no ailment whatever.’”
[Illustration: FIG. 56.--Drawing of specimen No. 2568 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 56.--“Specimen 2568. Presented by Sir William Blizard: Portion
of a rectum, of which the canal is at one part suddenly reduced to less
than a quarter of an inch in diameter by the thickening, induration,
and uniform contraction of its walls. The stricture is half an inch
in length, and terminates as suddenly as it commences. The intestine
above the stricture is very much distended, and its muscular coat is
hypertrophied; the part below it is small and atrophied.”
[Illustration: FIG. 57.--Drawing of specimen No. 2571a in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 57.--“Specimen 2571a. Presented by Dr. David Lawson (see _Lancet_,
Vol. I, p. 512, 1879): A portion of a rectum, the seat of a stricture,
which was excised. The bowel is much narrowed, and its walls are
thickened.
“From a woman, aged 34, who had suffered from symptoms of stricture of
the rectum for 8 years. Dilatation by bougies proved of no permanent
benefit. The stricture was hard, annular, admitted the tip of the
finger, and was situated 2 inches above the anus. It was excised
through an incision between the anus and coccyx, and the divided edges
of the bowel above and below were united by sutures. The patient
recovered from and was much relieved by the operation.”
The cases just quoted illustrate the typic advanced hypertrophy limited
to the rectal valve. The 2 cases following next are cases of tubular
stricture of the rectum. The definite boundary between the diseased
and normal tissues suggests the idea that the rectal valves are both
starting and limiting boundaries, and the tortuous course of the
stricture’s canal in Case 2571 seems also to support this idea, as will
be pointed out in the section on diagnosis.
[Illustration: FIG. 58.--Drawing of specimen No. 2571 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 58.--“Specimen 2571. Presented by John Hunter, Hunterian MS.,
Cases and Dissections, No. 59. A rectum, with the urinary bladder and
other adjacent parts. About 2 inches above the anus the canal of
the rectum is gradually reduced to less than half its usual size by
extensive thickening, induration, and contraction of the walls and of
the tissues around them. They are all converted into a uniform pale,
brawny, hard substance, like that of a cicatrix. This change, and the
stricture due to it, extend for about 3 inches up the intestine. The
mucous membrane lining the diseased part is superficially ulcerated;
above it the intestine is greatly dilated, and its coats are thickened;
below it is deeply wrinkled, but apparently not of unhealthy texture.
The following is most probably the history of the case:
“‘About the spring, 1785, General G. consulted me. He complained of a
sensation in the rectum, attended with a kind of difficulty in going to
stool when costive, and often a desire to go when there was nothing to
pass. I examined the rectum, and found, so far as I could reach with my
finger, a hard contracted ring surrounding the gut. I then pronounced
what the case was, and what would be the event.
“‘This hardness and thickening of the gut gradually increased, so as to
make it difficult at times to pass the feces, especially when costive.
At last, it occasionally became so difficult as to require the passing
of bougies and hollow catheters, which one could always pass the lower
stricture, but with difficulty passed the upper, which appeared to be 3
or 4 inches further up the gut.
“‘Clysters, purgatives, sedative and diluting, were occasionally thrown
up, which sometimes had their intended uses. In this way he went
on--sometimes better, other times worse--but upon the whole becoming
worse. At last, it became difficult to pass a bougie, catheter, or even
to throw up an injection, and which was attended with very disagreeable
symptoms for the time, as acidity in the stomach, fulness, oppression,
kind of hiccough, a vast rumbling in his bowels, and want of rest; but
he got occasionally a passage which gave him relief for a time.
“‘He was, of course, put on a very low diet, and such as was thought
best to answer the purposes of diet, while producing the least quantity
of excrements, as also such as tended as little to acidity as possible.
This was animal food in all the forms he liked best.
“‘All this art probably kept him alive for a twelve-month longer than
he otherwise could have lived, for without this attention one or two
costive days would have almost killed him, which I think I have often
seen.
“‘What appeared to be very singular, the constitution did not, till
the very last, seem to feel the disease or its consequences, for his
pulse kept slow and regular, never in the least hard; and when signs
of dissolution had taken place, the pulse was only weaker, but not
irritable. At last nothing passed through the strictures, either
downwards by stool, or upwards by way of clyster. The belly became
gradually fuller and fuller, which was principally air, as towards the
last he took but little food, and which was easily known by the sound
in patting on the belly. He became in some degree insensible to his own
situation, and in some degree less sensible of pain, which increasing,
he died in that kind of easy and insensible manner.
“‘On opening the body the colon was found very much distended with air
through its whole length; its transverse arch made a quick turn down to
near the pelvis, then up upon itself to the left side, and then down
the left, forming the sigmoid flexion; from all which turns, viz.,
making four, and being considerably distended, it appeared to fill
almost the whole belly.
“‘There was a good deal of feces in the colon, but not in the least
distending it.
“‘On putting the hand into the bottom of the pelvis was found a
considerable tumor, which, with the bladder and rectum, was removed;
but in this operation it was found that the tumor adhered closely to
the hollow of the lower part of the sacrum, so as to be obliged to lay
that bone bare in the removal of it.
“‘On slitting down the rectum, which was very large, it was found to be
very much thickened in its coats, and of a hardish, gristly texture, a
good deal like the turtle’s intestines. This increase of thickness was
to give it power to expel its contents.
“‘At the tumor the intestine contracted almost at once; and at its
entrance into the tumor its inner coats were thrown into loose folds,
so as to obliterate almost any appearance of a passage there; however,
I could readily pass the end of my finger into it, those folds easily
giving way. The tumor was next slit through, which showed a firm
increase of the gut, near an inch thick all round, and for three inches
in length. At the lower part it terminated all at once into the sound
gut, which we had often felt when alive. The inner surface had lost
entirely its natural appearance; was slightly rugged so as to appear
like villi.
“‘On introducing the pipe by the anus it was found to come butt against
the side of the upper part of the cavity of the tumor, where there
was a bend in the passage; but why a crooked pipe did not pass when
attempted to be passed by turning it to all sides, I cannot conceive.
Or why a bougie which was slightly bent, did not hit the hole, is not
easily accounted for; but what is more extraordinary than either, why
a clyster did not pass freely up; or why did not the wind or soft
excrements, that did yet lay, pass pretty readily down, while I could
pretty readily pass the end of my finger down from the gut above into
the tumor. The folds of the contracted part did not appear after death
to have been sufficient for an entire stoppage of this kind.”
The preceding case seems to illustrate that form of stricture which
is built upon two or more rectal valves and in which the walls of the
rectal chambers are involved and thickened. The mucous membrane is
longitudinally folded upon itself and incorporated in the organized
plastic exudate. The following case exhibits a tubercular tubular
stricture and is characterized by a destruction of the mucous membrane:
[Illustration: FIG. 59.--Drawing of specimen No. 2571c in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 59.--“Specimen 2571c. Presented by Dr. H. Handford (see _Trans.
Path. Soc._, London, 1888, page 117). From a lad, aged 17, who, four
months before death, began to suffer from wasting, irregular attacks of
diarrhea, and passed blood by the anus. Death resulted from purulent
peritonitis, the result of perforation of a rectal stricture by a
bougie. There were tubercle deposits in the upper lobes of both lungs
and in the head of the pancreas.
“Microscopic sections of the lungs, the nodules in the pancreas, and
all the lumbar and mesenteric glands showed masses of caseous material
with a few giant cells.
“The rectum exhibits a tubercular stricture which commences 3½ inches
above the anus. The stricture is 2 inches in length, moderately narrow,
and the mucous membrane covering it is superficially ulcerated. The
intestinal wall is somewhat thickened. Near the upper part of the
stricture is a small perforation, produced in an attempt to pass a
bougie through it.”
The following case is that of a stricture not builded on the rectal
valve. It is situated at the levator ani level, it is probably a
cicatricial product of disease which is not uncommon at this situation,
but it may have had its origin in an imperfect anorectal coalescence.
[Illustration: FIG. 60.--Drawing of specimen No. 2570 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 60.--“Specimen 2570. Presented by John Hunter: The lower part
of a rectum, with the anus. On the margin of the anus are several
large hemorrhoids, and the skin for a considerable distance around
it is excoriated. At the right side of the anus is an appearance of a
narrow granulating wound, as if a fistula had been there operated on.
Immediately above the anus the canal of the rectum is suddenly and
irregularly contracted to half an inch in diameter, but without any
apparent change in the structure of its mucous membrane. Above the
contraction it is unnaturally dilated, its coats are thickened, and the
tissues around it appear rather indurated and confused.”
Case 2567 belongs to the same class as the preceding.
[Illustration: FIG. 61.--Drawing of specimen No. 2567 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 61.--“Specimen 2567. From the Museum of Sir Astley Cooper: The
lower part of a rectum, the canal of which, about an inch from the
margin of the anus, is suddenly reduced to half an inch in diameter
by the deep annular fold of its mucous membrane. Above the fold the
mucous membrane appears healthy; below it is excoriated; and in one
place there is a narrow bridge of it, as if there had been an abscess
external to it, or as if a bougie had pierced it. The tissues around
the contracted part of the rectum are not manifestly diseased. There
are several external hemorrhoids at the margin of the anus.”
[Illustration: FIG. 62.--Congenital diaphragmatic stricture of the
rectum dependent on faulty development of third rectal valve. Composite
view.]
DIAGNOSIS.
_Fallacious Sounding._--Sounding the rectum with the patient in the
horizontal posture, supinated or semipronated, has been a feature of
the conventional method employed for the diagnosis of stricture of the
rectum for more than a century, and as a great array of fatalities
has not yet persuaded the profession to abandon the practice I feel
that at this moment an analytic study of the procedure would not be
unprofitable.
Sounding as a method of diagnosis requires three conditions: (1) that
the tube to be sounded have a recognized limit of distensibility;
(2) that its mobility in the direction of its axis be inappreciable,
and (3) that there be not at irregular intervals normal anatomic
obstructions in its channel sufficient to arrest the progress of a
sound.
These conditions obtain in the urethra which is fixed from extremity
to extremity within a mass of tissue which firmly supports it when the
organ is in a situation for the practice of this diagnostic maneuver.
The rectum on the contrary answers negatively to each of these three
propositions.
Seven or eight inches (17.78 or 20.32 cm.) of the rectum’s length are
not fixed; the lowermost inch (2.54 cm.) is the only portion muscle
bound (Fig. 21) and as this part is easily accessible to digital
exploration, to it, therefore, the method of diagnosis by sounding is
not applied. A little way above the upper border of the prostate, or
the pelvic floor in the female, the rectum is invested by a loop of
peritoneum which does not yoke the gut fixedly but anchors it loosely
in the abdominal cavity.
1. The distensibility of the abdominal rectum is governed by the
elasticity of the gut’s inherent coats and is not limited by a
comparatively unyielding musculofibrous wall supplied by the contiguity
of other parts twentyfold its own strength and several times its own
density and bulk, as is the case with the male urethra. The normal
range of distensibility of the rectum then may be said to be from
zero to three and a half inches (0 to 8.89 cm.) and consequently a
definite calibration for sounding is impossible. (Fig. 21). The sound
of a size which may enter the anus is not to be considered appropriate
for sounding the rectum in accordance with the principle governing
urethral catheterization which may be formulated in the aphorism; the
sound which fits the mouth should discover contractions in the tube.
The average diameter of rectal sounds is about one inch (2.54 cm.).
Two-thirds or three-fourths of the rectum’s expansibility, which may
be greater than three inches (7.62 cm.), must then of necessity be
sacrificed before rectal sounding will uniformly produce any definite
evidence of stricture, provided all other things are equal and
comparable to conditions obtaining in urethral catheterization.
2. Let us suppose, now, that there exist a considerable constriction
of this gut. In such a case the element of _mobility_ of a part of the
rectum in the direction of its axis enters into the problem. The range
of such movement of that part of the gut constricted is determined
by the length of its peritoneal attachment at that point, and of
neighboring portions of the gut, possibly by adhesions of the rectum
to other organs, and, also, depends upon whether the contraction be on
the side next the mesentery or opposite it. To discuss these special
points in detail would be to dwell upon the degrees of a fallacy. The
perplexing fact is this, and it is one that in itself should dethrone
the practice of sounding the rectum by the customary method for the
diagnosis of stricture. A bulb-tipped sound entering the rectum
and coming in contact with a contraction presenting an aperture of
lesser diameter than the sound’s end, will carry that part of the
gut above its normal situation to a point where the limits of length
and elasticity of its attachments arrest the movement, at which time
the sound will be stopped or else will enter, dilate and pass the
stricture, or, perhaps, puncture the gut.
When the sound encounters an obstruction it is the conventional
practice to observe how far the proximal border of the supposed
stricture is from the anus, which, let us say for purposes of
illustration, is in a given case exactly five inches (12.70 cm.). This
measurement having been determined it is now desired that knowledge of
the exact location of the stricture’s distal border be obtained, that
the length of the gut affected by the contraction may be estimated.
Having passed beyond the stricture the sound is tentatively withdrawn,
the shoulder of the bulb presently engaging the upper border of the
constriction will carry it downwards until arrested by the gut’s limit
of displaceability downwards; the exposed length of the shaft of the
sound is now measured and it is discovered that the most distant border
of the contraction instead of being more than five inches (12.70 cm.)
is but three inches (7.62 cm.) from the anus, or, paradoxically, it is
discovered that the farther border of the stricture is two inches (5.08
cm.) nearer the anus than the nearer border was!